Home Interview Consent Form

Home Interview Consent Form
Purpose of Interview
Delaware is conducting a Maternal Mortality Review Program. The purpose is to
identify factors that may help prevent deaths and to find ways to help families such as
yours in the future. To achieve these goals, we wish to interview family members who
have recently experienced a loss of a loved one who is of child bearing age. You have
been asked to participate in the program because of your recent loss. If you voluntarily
agree to participate, a Senior Medical Social Worker will ask you a series of questions
about the death of your loved one, including questions about their health, family, and use
of healthcare and social services. The interview will take place in your home, or a place
that you choose where you are comfortable, and it can be scheduled at a time that is
convenient for you. This interview will take about two hours. Your participation will
help us towards our goal of preventing deaths in Delaware.
Description of Potential Risk
Talking about the death of your loved one may prove difficult for you. The Senior
Medical Social Worker is not a professional counselor, but if you wish, she can provide
you with names of professional people who can help you deal with the loss. If during the
course of the interview, you feel you do not want to continue, you may ask the
interviewer to stop the interview at anytime. There is no expected risk of injury for
participants in this study.
Description of Potential Benefits
Participation in the interview may be a positive experience for you. You may find that
talking about the death of your loved one can help you in your grief process. Also, if
there are some needs that you or your family has, the interviewer can provide you with
information on the available community services that may be of help. In addition, the
information you provide to this program may help prevent the loss of other women in the
future.
Alternative Procedures
The alternative to participating in this interview is to choose not to participate at all.
Confidentiality of Records
All information that identifies you, your family or your health providers will be kept
confidential outside the review process. All Child Death, Near Death and Stillbirth
Commission staff and consultants have signed an oath of confidentiality. Therefore,
confidentiality will be protected to the full extent permitted by law. However, under
State statute the interviewer is obligated to report to the authorities reasonably suspected
child abuse or neglect disclosed by the interviewee.i We ask that if you are involved in
any ligation as a result of this death; that you do not participate in an interview until all
legal matters have been resolved.
Compensation
You will not be paid for participating in the interview.
Voluntary Participation
Your participation in this program is completely voluntary and you may refuse to
answer any questions that you do not wish to answer. You are also free to end the
interview at any time without consequences.
Questions
If you have any questions concerning the interview or the Child Death, Near Death
and Stillbirth Commission, you may call Joan Kelley at (302) 255-1764.
Consent
I have read this form and understand the purpose and conditions for participation in
the Maternal Mortality Review.
I hereby consent to participate in the program and the interview. I understand that all
information obtained from the interview will be strictly confidential and identifying
information will not appear in any publications or reports or be given to anyone outside
the review process.
Name:_________________________________________________________________
Signature:______________________________________________________________
Date:__________________________________________________________________
Interviewer’s Name:_______________________________________________________
Interviewer’s Signature:____________________________________________________
Date:___________________________________________________________________
i
All citizens are responsible for reporting any knowledge of child abuse or neglect in Delaware. Title 16, Sec. 903
is clear: §903. Reports required.
Any person, agency, organization or entity who knows or in good faith suspects child abuse or neglect shall make a report
in accordance with § 904 of this title. For purposes of this section, "person" shall include, but shall not be limited to, any
physician, any other person in the healing arts including any person licensed to render services in medicine, osteopathy or
dentistry, any intern, resident, nurse, school employee, social worker, psychologist, medical examiner, hospital, health
care institution, the Medical Society of Delaware or law-enforcement agency. In addition to and not in lieu of reporting to
the Division of Family Services, any such person may also give oral or written notification of said knowledge or suspicion
to any police officer who is in the presence of such person for the purpose of rendering assistance to the child in question
or investigating the cause of the child's injuries or condition.
16 Del. C. 1953, § 1002; 58 Del. Laws, c. 154; 60 Del. Laws, c. 494, § 1; 72 Del. Laws, c. 179, § 4; 77 Del. Laws, c. 320,
§ 1.;