Appendix
A A.1.3.f–
Pregnancy Loss Form
IF WOMAN CALLS TO TELL THE STUDY SHE LOST THE PREGNANCY:
INTERVIEWER INTSTRUCTION:
RECORD PARTICIPANT’S AGE FROM SYSTEM. IF PARTICIPANT IS NOT IN SYSTEM, ASK PARTIPANT TO PROVIDE HER AGE.
_______ YEARS
SPAgePregnancyLost
REFUSED ……………………………………………………...9--97
I’m so sorry for your loss. I realize it may be difficult for you to talk about this, but it’s important for us to know when you lost the baby. Can you please tell me the date when it happened?
DatePregnancyLost
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
______/______/____________ MM/DD/YYYY
REFUSED 9--97
DON’T KNOW 9--98
HARD EDIT:
IF DATE IS GREATER THAN 40 WEEKS BEFORE THE CURRENT DATE, DISPLAY, “You can not enter a date that occurred more than 40 weeks before today’s date. Confirm date and re-enter it.”
INTERVIEWER INSTRUCTION:
IF DATE OF PREGNANCY LOSS IS LESS THAN OR EQUAL TO 20 WEEKS FROM DUE, DATE GO TO PregLossInfoMedRecord. OTHERWISE, GO TO RequestInfoCopePregLoss.
Information about your pregnancy loss may help other women in the future. Would it be alright if
we sent you some information on how you can allow the study to request a copy of the medical
record for your loss?
PregLossInfoMedRecord
YES 1
NO 2
NOT APPLICABLE (TERMINATED PREGNANCY)…………
INTERVIEWER INSTRUCTION:
COMPLETE NEXT ITEM ONLY IF PREGNANCY LOSS MATERIALS ARE BEING PROVIDED BY THE STUDY CENTER.
DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH
PREGNANCY LOSS?
RequestInfoCopePregLoss
YES 1
NO 2
INTERVIEWER INSTRUCTION:
IF ABLE TO VERIFY PARTICIPANT IN SYSTEM, GO TO EndPregLossCall. OTHERWISE, IF UNABLE TO VERIFY PARTICIPANT IN SYSTEM, GO TO PregLossContactInfo.
_________________________________________________________________________
Because, I am unable to pull up your record in the System right now, would you please provide
me with your name, address, and phone number so that we can contact you in case we
need additional information.
PregLossContactInfo
What is the best phone number to reach you?
|__|__|__| |__|__|__| -- |__|__|__|__|
PHONE NUMBER
PregLossPhoneBest
PregLoss PhoneType Home Work Cell Other (Specify) __________
INTERVIEWER INSTRUCTION:
IF BEST PHONE IS NOT HOME PHONE, THEN GO TO PregLossPhoneHome.
OTHERWISE, GO TO PregLossHaveEmailAddress.
What is your home telephone number?
|__|__|__| |__|__|__| -- |__|__|__|__| No home phone
PHONE NUMBER
PregLossHome Phone
NONE/NO LAND LINE 9—90
REFUSED 9—97
DON’T KNOW 9—98
What is your mailing address?
PSMailAddressStreet - Mailing address - street
PSMailAddressCity - Mailing address - city
PSMailAddressState - Mailing address - state
PSMailAddressZip - Mailing address - Zip
INTERVIEWER INSTRUCTION:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________STREET/ PO BOX
_____________________________________CITY
|___|___| STATE |___|___|___|___|___| ZIP CODE
REFUSED ……….. .9—97
DON’T KNOW 9—98
Do you have an e-mail address where we can contact you?
PregLossHaveEmailAddress
YES 1
NO 2
REFUSED ……….. ..9—97
DON’T KNOW 9—98
What is the best e-mail address to reach you?
_________________________________________________
PregLossEmailAddress
INTERVIEWER INSTRUCTION:
ENTER AND CONFIRM E-MAIL ADDRESS.
Again, I’d like to say how sorry I am for your loss. {We’ll be sending you information about
asking for permission to obtain the medical records}. {{We’ll also be/ we’ll be} sending the
information packet you requested as soon as possible.} {We’ll call you again in a few months to
see how you’re doing}. Thank you for your time.
EndPregLossCall
DISPLAY INSTRUCTIONS:
IF PregLossInfoMedRecord = “1”, THEN DISPLAY, {We’ll be sending you information about
asking for permission to obtain the medical records}.
IF PregLossInfoMedRecord = “1” and RequestInfoCopePregLoss = “1” THEN DISPLAY, “{We’ll also be sending the information packet you requested as soon as possible.}”.
IF PregLossInfoMedRecord ≠ “1” and RequestInfoCopePregLoss = “1” THEN DISPLAY, “{We’ll be sending the information packet you requested as soon as possible.}”.
IF SPAgePregnancyLost >17 and < 50, THEN DISPLAY, “{We’ll call you again in a few months to see how you’re doing.}”.
Revised 7/17/08
| File Type | application/msword |
| File Title | Pregnancy Loss Form |
| File Modified | 2008-09-15 |
| File Created | 2008-09-15 |