Possible GBS Infection Story Form

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Possible GBS Infection Story Form

Please include details about your baby's possible experience with group B strep that could help prevent another family from experiencing the tragic effects of infection or other harm to their baby. Please also include details as to why the cause was not determined to help direct our awareness efforts. If you have difficulty posting your story, please email [email protected].

* Indicates required field

Your baby's name or nickname: *

For parents of GBS survivors, we suggest that you do not include your baby's last name for their privacy as they become adults.

Country *

Category of GBS experience (select all that apply) *

Miscarriage Stillbirth Infant death GBS survivor Preterm birth C-section Mother's membranes stripped Other

How far along was your pregnancy? *

Examples: 12 weeks, 30 weeks, full-term

Were you tested for GBS during your late 3rd trimester? *

If you were tested, what was the test result? *

Besides testing, why do you think your baby may have been harmed by GBS? (select all that apply) *

Had GBS in my urine during this pregnancy I had a fever around the time my baby was harmed My baby had signs and symptoms consistent with a GBS infection Other

Date your baby was born, stillborn, or miscarried:

Day *

Month *

Year *

Date your baby died, if applicable:

Day *

Month *

Year *

How old was your baby when possibly harmed by GBS? *

Examples: 34 weeks gestation, at birth, 3 days old, 4 months old

Why was the cause not determined? *

If you spread GBS awareness, please share how: *

Examples: gave GBS brochures to all the pregnancy clinics in my town, share info on social media, wear a GBS awareness ribbon, etc.

Your story of your baby’s possible experience with GBS: *

Your Name: *

First

Last

How would you like your name to appear at the end of your baby's story page: *

Your Email *

(We require your email address in case we need to contact you to clarify details before posting your story and to tell you when your story has been posted. GBSI will not share your email address with anyone.)

If desired, you may attach a photo of your baby to be included with your story: *

Max file size: 20MB

Choose any: *

I give permission to have this story shared on GBSI's social media (optional) If included, I give permission to have my baby's photo shared on GBSI's social media (optional) I give permission to have this story used by GBSI for educational purposes, such as presentations (optional) If included, I give permission to have my baby's photo used by GBSI for educational purposes, such as presentations (optional)

Submit

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Possible GBS Infection Story Form

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