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

  1. Purpose:
  • To determine if text messaging is an acceptable method of postpartum depression screening in the OB-GYN center patient population.
  • To determine the highest yield screening questions that will flag patients who require intervention.
  • Through text messaging, we hope to better understand the mental health needs of OB-GYN center patients.
  • Freedom to withdraw or not respond: Your participation in this program study is voluntary. You may refuse to take part or stop participating at any time. You can take a break at any time and ask questions at any time. If at any time you choose to stop participating, let us know either in person or using the interviewers’ contact information below. You may opt-out of receiving text messages from this project by [replying STOP] to the last text message you received from us. If you opt-out of receiving text messages, you may no longer be able to participate in the project.
  • Freedom to decline questions: Most interviewees will find the discussion interesting and thought-provoking. If, however, you feel uncomfortable in any way during the interview session, you have the right to decline to answer any question or to end the interview.
  • Information we will collect: We will collect text message responses but the responses will not be linked to your name or medical chart. We may collect information about you and your child(ren), including names, ages, genders, address, email address, phone numbers, opinions,

responses to research questions, and personal background. All of this information will remain confidentialanonymous.

  • Privacy and confidentiality: Information collected will be shared within our quality

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.

  • Medical liability: We are not liable for your medical care or acting upon medical information shared via text message. We will refer you to your obstetrician or primary care provider if you have any medical questions. This is a behavioral health resource, for any medical concerns, contact the OB-GYN center at 215-938-4816.
  • Interpreter: If English is not your first language, an interpreter may be present during your interview sessions. The interpreter will also keep your information confidential.
  • Resources: You confirm that you have been provided with the below maternal mental health resources and that you are invited to utilize those resources if you have postpartum mental health challenges.

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.

  • National Suicide Hotline: 1-800-273-TALK
  • Bucks County Mobile Crisis: 1-877-435-7709
  • Philadelphia County Mobile Crisis: 215-685-6440
  • Montgomery County Mobile Crisis: 1-855-634-4673
  • National Drug & Alcohol Treatment Hotline: 1-800-662-HELP
  • Postpartum Support International https://www.postpartum.net/ Call or text “Help” to 1-800-944-4773

 

  1. Ownership of the research dataUse of Information for Research: All information shared with us will be treated with care according to applicable privacy and information security legal requirementspractices. Your identifiable information may be removed from the data collected during this project, and the de-identified data may be used for future research without additional consent from you.

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

Jessica.Gaulton@jefferson.edu Bethany.Perry@jefferson.edu 

267-602-4215 215-481-2194

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].

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Signature Certificate
Document name: User Consent - From Clinic
lock iconUnique Document ID: 94286a00b3496a8f1bff57bfba510b0c27e3d859
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April 30, 2022 12:48 pm ESTUser Consent - From Clinic Uploaded by Chris Kuruppu - chris@mommi.us IP 209.196.199.35, 34.102.219.146