Making Every Baby Count
9789241511223-eng
9789241511223-eng
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INFORMED CONSENT FORM (INTERVIEWER COPY)<br />
Informed Consent Form for verbal autopsy (VA) interviews (for stillbirths and<br />
decedents 1–28 days)<br />
Hello. My name is ____________________ and I am working with _________________ (AGENCY) a partner<br />
of the Ministry of Health. We are conducting a survey in this district that asks about health issues of<br />
newborn babies.<br />
I am asking you to take part in this survey because I am trying to learn more about the causes of death<br />
among stillbirths and newborn babies. We are asking all households in this district that reported a stillbirth<br />
or death to a newborn baby since _________ to participate in this survey. The Government and its stakeholders<br />
have been improving access to health care and the provision of health services in this district. The<br />
information that you provide will help us understand health challenges faced by newborns.<br />
I am visiting you today because we were informed about the death of your baby. I am here now to ask you<br />
about the circumstances that led to his/her death. This information will help the government and its stakeholders<br />
to understand better ways through which they can improve neonatal health services and help us<br />
know whether the improvements in health care planned for your district are helping. The interview will take<br />
between 30 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential<br />
and will not be shown to other persons.<br />
Participation in this interview is voluntary, so if we should come to any question you don’t want to answer, just<br />
let me know and I will go to the next question; or you can stop the interview at any time. You should be aware<br />
that your answers about the deceased may say something about your own health. However, we hope that you<br />
will participate in this survey since your views are important. The information that you provide is strictly confidential.<br />
At this time, do you want to ask me anything about the information we are collecting or the survey?<br />
May I begin the interview now?<br />
No, consent for participation not given<br />
Yes, consent for participation given<br />
Yes, consent for participation given<br />
Interviewer signature: _________________________________________<br />
Interviewer signature: _________________________________________<br />
Respondent signature: ________________________________________<br />
OR Respondent thumb print:<br />
Date ________________________________<br />
If you have any questions about this survey, please contact:<br />
Name (Principal investigator)<br />
Institutional affiliation<br />
Telephone<br />
If you ever have questions about your rights or ethics as a participant in this study, please contact:<br />
Name (Principal investigator)<br />
Institutional affiliation<br />
Telephone<br />
SIGNATURE OF VA SUPERVISOR:<br />
__________________________________________________<br />
VA SUPERVISOR CODE:<br />
_______________________________<br />
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS<br />
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