Stool Sample Collection Study Sign-Up

Name*
First Last
Please make sure to fill in either your email or phone number. We will need to be able to contact you for study purposes.
Email
Phone
Community*
Peer Support Counselor Name
Peer Support Counselor Phone Number
View Breastfeeding Promotion Study Consent Form
View Breast Milk Sample Collection Study Consent Form
View Stool Sample Collection Study Consent Form
Consent*
- 1. I have read and understood the information of the study and I agree to participate in the study.
- 2. I understand that I can stop participating in the study at any time, for any reason, and this will not affect my future medical treatment.
- 3. I agree to cooperate with the study doctors and will tell them if I experience any side effects, symptoms or changes in my health or pregnancy
- 4. I understand that my name, address, and telephone number will be kept private and all the identifying information will be stripped. I give permission to the health organizations mentioned above to review my medical records.
- 5. I agree to let the study staff and my family doctor know any discomfort that happen during study program sessions, or let them know any discomfort happens later on, and the growth information of my baby.
- 6. By agreeing to the document above, I am clear that none of my legal rights are being waived. I understand that I will be given a copy of the signed and dated Information and Consent Form.
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