Attach A6. PLSND Follow-Up SAQ and Release Forms Letter

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

Follow-Up Questionnaire and 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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Follow-Up Questionnaire and Release Forms Letter: PLSND

Dear [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 Authorization to Obtain Information from Medical Records for the National Children’s Study. 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 Parent or Guardian Authorization to Obtain 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. 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 [email protected].

Best regards,

Name

Full Name

Organization

Phone

Email