Bangalore Birth Network Maternal Health Survey Consent Agreement

By filling this survey you:

1) Confirm that you are over 18 years of age

2) Confirm that you have given birth in Bangalore in the past three years

3) Agree that you will not fill more than one survey in a 12 month period

4) Voluntarily agree to answer all questions honestly, to the best of your recollection and will not submit false, inaccurate, misleading, defamatory, or libelous content, either data or commentary, about any health care professional or health care facility.

5) Understand your identity or any personally identifying information will not be shared with the public or linked to your answers in a public manner.

6) Agree to give your email ID if you wish to stop filling the survey before it is complete and continue filling it at a later time knowing that your email ID will be used only for the purpose of giving the option of completing your partially filled survey and will not be shared with any outside party or used for any other purpose.

7) Agree to allow your responses to be entered into a database kept by the Bangalore Birth Network wherein responses are combined and reported as summary data to the public, health care facilities, health care practitioners, policy makers, advocacy groups and others. Understand that survey data may be collated, analyzed, and used in publications without revealing identity of respondents

8) Understand that you will not be compensated for filling the survey.

9) Understand that you will not be contacted in the future by the BBN as a result of filling the survey

10) Understand there are no direct personal benefits to you for filling out The Maternal Health Survey in whole or in part. It will take approximately thirty (30) minutes to complete depending on your birth experience and your Internet connection. Although we do not anticipate any risk to you, there may be a small chance that recalling a traumatic or difficult birth experience may trigger unpleasant or traumatic memories. By participating in whole or part in Maternal Health Survey, you agree to assume that risk and will hold Bangalore Birth Network harmless for any harm, emotional pain, or injury that might result.

11) Understand that while there is no direct benefit to you from filling the survey there may be a benefit to the public as data are made available to consumers, policy makers, researchers and health care practitioners on interventions in the perinatal period.

12) Understand the goal of the Maternal Health Survey is to foster greater transparency in maternity care to empower the consumer and improve the quality of care.

13) Understand the objectives of the BBN Maternal Health Survey are to:

a. Provide a forum for women to relate their birth experience in a way that can help other women.

b. Provide women giving birth in Bangalore with an impression of their options through other women's

c. Build a public archive of information which raises public awareness and highlights the differences between

d. Provide aggregate data to interested individual providers and institutions for their quality of care birthing experiences providers and institutions improvement efforts.