Making Every Baby Count

INFORMED CONSENT FORM (INTERVIEWEE COPY)
Informed Consent Form for verbal autopsy (VA) interviews (for stillbirths and
decedents 1–28 days)
Hello. My name is ____________________ and I am working with _________________ (AGENCY) a partner
of the Ministry of Health. We are conducting a survey in this district that asks about health issues of
newborn babies.
I am asking you to take part in this survey because I am trying to learn more about stillbirths and the causes
of death among newborn babies. We are asking all households in this district that reported a stillbirth or
death to a newborn baby since _______________ to participate in this survey. The government and its stakeholders
have been improving access to health care and the provision of health services in this district. The
information that you provide will help us understand health challenges faced by newborns.
I am visiting you today because we were informed about the death of (your baby). I am here now to ask you
about the circumstances that led to his/her death. This information will help the government and its stakeholders
to understand better ways through which they can improve neonatal health services and help us
know whether the improvements in health care planned for your district are helping. The interview will take
between 30 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential
and will not be shown to other persons.
Participation in this interview is voluntary, so if we should come to any question you don’t want to answer, just
let me know and I will go to the next question; or you can stop the interview at any time. You should be aware
that your answers about the deceased may say something about your own health. However, we hope that you
will participate in this survey since your views are important. The information that you provide is strictly confidential.
At this time, do you want to ask me anything about the information we are collecting or the survey?
May I begin the interview now?
No, consent for participation not given
Yes, consent for participation given
Yes, consent for participation given
Interviewer signature: _________________________________________
Interviewer signature: _________________________________________
Respondent signature: ________________________________________
OR Respondent thumb print:
Date ________________________________
If you have any questions about this survey, please contact:
Name (Principal investigator)
Institutional affiliation
Telephone
If you ever have questions about your rights or ethics as a participant in this study, please contact:
Name (Principal investigator)
Institutional affiliation
Telephone
106 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS