User Consent - From Clinic
CONSENT FOR PARTICIPATION IN MOMMI SUPPORT PROGRAM QUALITY IMPROVEMENT PROJECT
Mommi in partnership with the Abington Hospital – Jefferson Health OB-GYN center, are offering patients a text-based wellness program carrying out a quality improvement project to provide additionalimprove maternal support during and after pregnancy as well as gain insight into how to improve postpartum depression screening.
Please visit www.mommi.us to learn more about the program. You may sign up directly on the website anytime. By signing up for this program, you agree to receive both autodialed and manually dialed text messages in relation to this program from [Mommi and our partner].
Save this number as “Mommi” on your phone so you know it’s us: 912-446-6664
responses to research questions, and personal background. All of this information will remain confidentialanonymous.
improvement team. Your confidentiality as a participant in this study will remain secure. The researchers will not identify you by name in any reports using information obtained from the research. Instead, the researchers will use a study number or a pseudonym rather than your name.
By signing this consent form, you are giving us consent to use your texted and verbal statements, but not your name, for the purposes of your participation in the program, demonstration and evaluationand to improve the services provided by the program. Aggregated and de-identified Summary data from this research may be used in publications or presentations for educational and quality improvement purposes.
We will send your post-partum screening (EPDS) scores collected by text message through this program to your OB provider(s). as well as We may also notify your OB provider of certain medical or mental health information or concerns . Such information
information collected through this project about your mental health may be copied into your medical record.
For any non-urgent medical concerns, contact the OB-GYN center at 215-938-4816.
If you feel like you are in a crisis or having thoughts of hurting yourself or anyone else, please go to the nearest emergency room or call 911. These resources are available 24 hours a day, 7 days a week.
If you cancel permission to use your information, the researchers will stop collecting additional information about you. However, the research team may use and disclose information that was gathered before they received your cancellation, as described above.
If you want the researchers to stop collecting additional information about you, contact the interviewers listed below. You may also reach out to them with any questions about the project.
Jessica Gaulton, MD, MPH Bethany Perry, MD
ACCEPTED & AGREED: I have read this Consent for Participation and understand the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to allow my OB team to receive my EPDS scores collected by text message as well as information collected through this project about my mental health. By providing my cell phone number and signing below, I consent to receiving both autodialed and manually dialed text messages in relation to this program from [Mommi and its partner].
DATE CELL PHONE NUMBER
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If you have questions about the contents of this document, you can email the document owner.
Document Name: User Consent - From Clinic
Agree & Sign