Annex 5: Informed consent form for mothers

Introduction and Purpose of the research:

I am ----------------------------------------, and I work with the School of Public Health,

Makerere University. We are conducting a health facility-based survey in order to

understand family planning service delivery.

In order to improve uptake of modern family planning services the district and

stakeholders require current information on barriers to uptake of modern family planning

services in child health clinics so as to design appropriate interventions

Procedure

We/I therefore, invite you to take part in this survey. If you accept, you will be required

to answer questions which will be administered by [………………………………………

name of research assistant].

To find answers to some of the questions, we invite you to take part in this study. If you

accept, you will be required to answer questions concerning the care you have just

received. This information is very important to us and will inform design of interventions

to improve delivery of family planning services for mothers in health facilities in this

district and other places in Uganda. You can choose to accept or not to accept to

participate in the interview

This interview will take about 20 minutes to complete. However, you can ask me to stop

at any time.
If you do not wish to answer any of the questions included in the survey, you may skip

them and we move on to the next question. The information recorded is considered

confidential, and no one else except the research team will have access to the survey.

Risks and Discomforts:

You may refuse to answer any question or not take part in a portion of the survey if you

feel the question(s) make you uncomfortable.

Benefits:

There will be no direct benefit to you, but your participation will help the district and

stakeholders design appropriate interventions to improve uptake of the family planning

services in order to improve maternal and child welfare in the district and the country at

large.

Incentives:

You will not be paid money or in kind for participating in the research.

Confidentiality:

The information that we collect from this study will be kept confidential. Information

about you that will be collected from the study will be stored in a file that will not have

your name on it, but a number assigned to it instead. The name associated with the

number assigned to each file will be kept under lock and key and will not be divulged to

anyone except the research team and the sponsors.

Right to refuse or withdraw:

You do not have to take part in this research if you do not wish to do so, and you may

stop participating in the interview at any time that you wish.

Who to contact:

If you have any questions you may ask those now or later. If you wish to ask questions

later, you may contact the following: