Pregnancy Loss, Stillbirth, & Neonatal Death Interview

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

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

The National Children’s Study

Telephone Medical and Death Certificate Release Forms Letter: PLSND

Dear [Insert 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 HIPAA Authorization for Use and Disclosure of Health Information.

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 HIPAA Authorization Form for Release of 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.

We expect that it will take you about 5 minutes to review and complete each of the release forms. 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,

[Insert Full Name]

[Insert Organization]

[Insert Phone]

[Insert Email]

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.

QUE Telephone Medical Records and Death Certificate Release Forms Letter: PLSND, MDES 4.0, V2.0 1