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Laurie Van Damme
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For Grieving Families
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Survey for Families Experiencing Perinatal Loss
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1. First, I am truly sorry for your loss. Your opinions are important and I encourage you to be as honest as possible while taking this brief survey. Your time is greatly appreciated. Which of the following best describes you?
Mother (who has lost a baby)
2. OVERALL, did you find the hospital staff CARING and SUPPORTIVE during your stay and interactions with them?
3. Please select all of the services you received (from the hospital) including any items that were given to you during your stay or following your loss.
Written information about grief/loss
Information about community resources and/or support groups
Lock of hair (if appropriate)
Baby was bathed and dressed
Memory box to keep baby's items
Blanket and clothing that baby was wearing
Memorial video (provided by hospital, NOT outside organization)
4. If you received photographs, how many did you receive? (select all that apply)
I did not receive any
I received an undeveloped 35mm film
I received a CD or disk of digital pictures
Less than 5 pictures (either printed or digital)
More than 5 but less than 10 (either printed or digital)
More than 10 but less than 25
More than 25 pictures
More than 50 pictures
More than 75
5. Please select all statements that are true.
At least one of my caregivers provided exceptional care to me and my family members during my hospital stay
At least one of my caregivers said something that was perceived as hurtful and/or insensitive
Staff spent a lot of time with me but gave me private time when it was needed
Staff seemed to avoid me
I was encouraged by the staff to spend time with my baby
I was encouraged to hold my baby
I was encouraged to unwrap, look at and touch my baby
I felt pressured into looking at or holding my baby and I wish I would not have
I feel as though I have few or no memories of my baby
I wish I had more memories of my baby
I wish I had fewer memories of my baby
Someone from the hospital followed up with me after I was discharged (by phone, email, or card)
Talking about my baby is important to me
Sometimes I fear that I will forget my baby
Sometimes I fear that others will forget my baby
I wish I had some type of memorial video of my baby
I showed friends or family members a picture of my baby
I haven't showed friends a photo of my baby but I want to...I'm just afraid of how they may react or what they may think
At the time, I didn't want any pictures but now I wish I had some
At the time, I didn't want any pictures but I'm glad they took some for me anyway
6. Looking back, if things could be different I would:
Spend more time with my baby
Take more pictures of my baby
Take pictures of my baby with other family members or friends
Choose not to see or hold my baby because it was too painful
Choose another hospital because they did not seem very sensitive to my situation
Bathed and/or dressed my baby
Allow more people to see my baby (siblings, family members, friends)
Not change anything. Under the circumstances, it was probably the best it could have been.
Other (please describe)
7. With regards to the hospital where you received care, what area(s) could benefit from improvement?
Time available to spend with me and my family
Materials and written information given to us
Mementos given (memory box, clay molds, blankets, memorial video, etc)
Memorial video (I would want one)
General staff training (staff didn't seem well trained to care for me during my loss)
8. In what city and state did you receive care during your loss?
9. In what year did you experience your loss?
10. How many weeks pregnant were you when your baby passed away?
Less than 12 weeks
12 -16 weeks
Greater than 36 weeks
My baby passed away in the NICU or at home (neonatal death)
11. If you became pregnant again following your loss, did you go back to the same hospital as where your loss took place?
I did not get pregnant again
If there is anything else you wish to share, please do so here. Your opinion is very important to me and any input you can provide is greatly appreciated. Perhaps you just want to share your story -- please know that I would be honored to read it.