I, _________________________________________ agree to participate in the “Women’s stories of coping with ectopic pregnancies: A qualitative study to explore how social workers can help women during times of pregnancy loss” study conducted by Dr. Shannon Mokoro, School of Social Work, Salem State College and Laurie Grant, LCSW. I understand this project is studying the experiences of women of have been diagnosed with an ectopic pregnancy.

As part of my participation in this study, I understand that I will complete a pre-screening survey and if selected, participate in face-to-face interview. I understand that I may receive no compensation for my participation in this study. I understand that I may not receive any direct benefit from my participation in this study.

I understand my participation is completely voluntary and that I may withdraw at any time from this study. I may decline to participate in any portions of this study with which I feel uncomfortable.

I understand that my name or identity will not be used in reports or presentations of the findings of this research. The information provided to the researchers will be kept confidential with the exceptions of information which must be reported under Massachusetts’ law.

I have read and understand this information and agree to participate in this study. I will be offered a copy of this form to keep.

Participant’s Signature _____________________________ Date _______________

Investigator’s Signature ____________________________ Date _______________

For questions or concerns about the research, please contact Dr. Shannon Mokoro at (978) 542-6610. For concerns about your treatment as a research participant, please contact the Institutional Review Board (IRB), Sponsored Programs & Research Administration, MH 204, Salem State College, 352 Lafayette Street, Salem, MA 01970. (978) 542-7756 or (978) 542-7177.

A copy of this signed form is as good as the original.

* 2. Please provide your full first name and the first initial of your last name, city, email, and phone number. This information will only be available to the two researchers and will not be shared with anyone.

* 3. What is your marital status?

* 4. At the time of your ectopic(s) did you know you were pregnant?

* 5. If you answered "yes" to question 3 - How far along were you when you were diagnosed with your first ectopic?

* 6. Did your ectopic pregnancy lead to you needing surgery?

* 7. If you answered "yes" to question 5 at which hospital was your surgery performed?

* 8. Did your doctor, nurse, or other medical personnel offer you a referral to a social worker/therapist/loss group?

* 9. We are interested in writing a book to provide hope, support, and comfort to other women who have experienced ectopic pregnancies and did not know where to go or what to do. Your story may inspire someone else in this situation. If based upon your above answers, we feel you meet our criteria, would you be willing to meet with us to further your interview and then possibly contribute your story to a book project? All contributors have the option to share their story anonymously.