Attach A8. PLSND Telephone Medical Records and Death Cert Release

Telephone Medical Records and Death Certificate Release Forms Letter: PLSND, Phase 2f

Telephone Medical Records and Death Certificate Release Forms Letter: PLSND

Event:	Pregnancy Visit 1, Pregnancy Visit 2, Birth
Domain:	Questionnaire
Type of Document:	Letter
Recruitment Groups:	PBS
Version:	1.0
Release:	MDES 3.3

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Telephone Medical Records and Death Certificate Release Forms Letter: PLSND

Dear [Name],

Thank you for speaking with us recently about your loss. As we told you on the phone, we are sending you a packet to complete your participation in the National Children’s Study. This packet should include:

1. Two copies of a medical records release form;

2. [INCLUDE COPY FOR PARTICIPANT AND 1 COPY FOR EACH BABY STILLBORN OR THAT DIED] copies of the death certificate release forms; and,

3. A pre-addressed and pre-paid U.S. Postal Service priority mail envelope.

Please review the record release forms that are enclosed. To better understand your loss, we would like to ask your permission to review your medical record related to your most recent pregnancy. If you agree to allow us to access your medical record, please complete the medical records release form entitled Authorization to Obtain Information from Medical Records for the National Children’s Study.

In addition, as your recent pregnancy ended in a stillbirth or your infant died after being born alive, your baby’s death certificate can give us important information about the cause of death. We would like to request permission to access your baby’s death certificate. If you agree to this, we would like you to review and complete a death certificate release form entitled Parent or Guardian Authorization to Obtain Death Certificate. If your loss included the stillbirth or death of more than one baby, we would like you to complete the death certificate record release for each deceased baby.

Please return the completed medical record release and death certificate release forms in the priority mail envelope within 3 days. The second copy of each form is yours to keep.

After you return the forms, you will be mailed $25 to thank you for your participation. As a reminder, your participation is voluntary.

If you have any questions or concerns, you may also contact me on my toll-free number at 1-XXX-XXX-XXXX or by email at XXX@XXXX.xxx.

Best regards,

Name

Full Name

Organization

Phone

Email