Breech Birth Podcast - Consent and Survey Form

Breech Birth Podcast - Consent and Survey Form

Please read the following consent statement carefully. You will be asked to share your birth story, knowledge or experience with breech birth, which may be used publicly. Additionally, there are survey questions at the end of this form.
Full Name of the Participant*

First NameLast Name
Thank you for your interest in sharing your story/knowledge/experience with the Breech Birth Podcast, a podcast dedicated to amplifying women's voices around breech birth experiences. By completing this form, you are voluntarily submitting information that may be used in podcast episodes, social media content, You Tube channel or related materials and research. Your participation is entirely voluntary, and you may choose to remain anonymous or be identified by your first name, pseudonym, or full name — according to your preference. You have the right to withdraw your story at any time before it is published. Once the story is published it will remain public. We may contact you for clarification or follow-up if needed. Your responses will be treated with respect and stored securely. Submitting this form does not guarantee inclusion in an episode, but all stories are appreciated and deeply valued. By completing this form, you agree to not identify any health care worker or birth worker e.g. doula, photographer etc. by name whilst sharing your story to protect their identity. PLEASE SELECT ONE OF THE FOLLOWING OPTIONS:*

I have read the above and consent to share my breech birth story or knowledge or breech birth experience for use in the podcast and related materials.I have read the above and do not consent to share my breech birth story or knowledge or breech birth experience for use in the podcast and related materials.
Breech Birth Story Questions

If you are a practitioner please write N/A for the questions that are not applicable to you
Email*
example@example.com
Where are you located?*
eg. Sydney NSW Australia.
Do you wish to remain anonymous? If so, please share a pseudonym.*
What year was your baby born?*
*Write N/A if you are a practitioner
What kind of care did you receive during pregnancy, labour, and birth?*
eg. hospital care, MGP, private midwifery, private obstetrician, freebirth with/without antenatal care. *Write N/A if you are a practitioner
Was this a surprise or planned breech birth?*
*Write N/A if you are a practitioner
How was your breech baby born?*
eg. vaginal, caesarean. *Write N/A if you are a practitioner
Breech Birth Practitioner or Researcher Questions

If you are sharing your breech birth story please write N/A for these questions
Select which best describes you:*

MidwifeObstetricianResearcherOtherN/A
Please share a brief description of your experience with breech birth and/or breech research*
*Write N/A if you are sharing your birth story
Please share any specific topics, points that you would like to cover in your interview*
*Write N/A if you are sharing your birth story
Please share your social media handle to be tagged*
*Typer N/A if you do not want this
Thank you for completing the Breech Birth Podcast consent and questionaire. We will be in touch as soon as possible.
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Breech Birth Podcast - Consent and Survey Form

Breech Birth Story Questions

Breech Birth Practitioner or Researcher Questions