PLSNDSAQReleaseLetter

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

The National Children’s Study

Follow-Up Questionnaire and Release Forms Letter: PLSND

Follow-Up Questionnaire and Release Forms Letter: PLSND, Phase 2g

Dear [Insert Name],

We are sorry to hear of your loss and appreciate that you have agreed to complete the Follow-Up Questionnaire: PLSND by mail for the National Children’s Study (NCS). The NCS is an observational research study led by the National Institute of Child Health and Human Development (NICHD) in collaboration with other federal government partners to help better understand how children’s health can be improved.

This mailing includes all the materials you will need to participate. Please carefully review everything in the packet. This packet should include:

1. Follow-Up Questionnaire: PLSND;

2. Two copies of a medical records release form and death certificate release form; and,

3. Two pre-addressed and pre-paid U.S. Postal Service priority mail envelopes.

If you agree to participate, please complete the Follow-Up Questionnaire: PLSND and return it in one of the enclosed priority mail envelopes within 3 days.

Also 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 obtain your medical record, please complete the medical records release form entitled HIPAA Authorization for Use and Disclosure of Health Information. In addition, if 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. If your baby was stillborn or died after birth, we would like to request permission to obtain 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. Please return the completed medical record release form and, if applicable, the death certificate release form in the second priority mail envelope within 3 days. The second copy of each form is yours to keep.

The questionnaire should take about 15 minutes to complete. It may take you about 5 minutes to review and complete the release forms for your medical record and, if applicable, your baby’s death certificate. After you return these, you will be mailed $25 to thank you for your participation.

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@XXX.xxx].

Best regards,

[Insert Full Name]

[Insert Organization]

[Insert Phone]

[Insert Email]

Public reporting burden for this collection of information is estimated to average 1 minute 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 Follow-Up Questionnaire and Release Forms Letter: PLSND, MDES 4.0, V2.0 1