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Appendix AA.1
Hospital Data Request Form - ENGLISH


								<TODAY’S DATE>

<NAME>
<NAME OF HOSPITAL>
<RECORDS DEPT>
<ADDRESS>


Dear Hospital Records Administrator,

Westat is a contract research organization headquartered in Rockville, Maryland that is under contract to the United States Department of Agriculture, Food and Nutrition Service to conduct a national Women Infant and Children (WIC) Feeding My Baby Study to understand birth, health, growth, and early feeding practices of infants and toddlers between birth and 24 months of age. To this end, we are obtaining hospital birth records on all infants enrolled in the study and the mother’s hospital delivery record for the corresponding birth of the enrolled infant.  

Enclosed you will find the Medical Records Release Form for:

Mother’s Name:   <MOTHNAME>    Date of Birth: <M_DOB>   Delivery Date:  <DLDT>

Infant Name: <INFNM>   Date of Birth: <I_DOB>

Please call or e-mail, <_____________________> at xxx-xxx-xxxx, [email protected] should you have any questions or require assistance.  If at all possible we request that we receive the records within 4 weeks of receipt of this request. They can be transmitted electronically, faxed, or via standard postal service.
   
Medical Data Management Group 
WESTAT 
1500 Research Boulevard, TB132 
Rockville, MD  20850
FAX:  240-314-5895 

Thank you very much for your assistance with this important research study.  

Sincerely,


Gail Harrison, PhD
Feeding My Baby, Principal Investigator

Suzanne McNutt
Feeding My Baby Project Director

Tameka Owens
USDA, Food and Nutrition Service