Your baby's name or nickname: *
Your country: *
State/Province:
-Unspecified- Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) American Samoa (AS) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Washington D.C. (DC) Florida (FL) F.S. of Micronesia (FM) Georgia (GA) Guam (GU) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Marshall Islands (MH) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) N. Mariana Islands (MP) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Palau (PW) Pennsylvania (PA) Puerto Rico (PR) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Virgin Islands (VI) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY)
-Unspecified- Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland (NF) Nova Scotia (NS) Northwest Territories (NT) Ontario (ON) Prince Edward Island (PE) Quebec (QC) Saskatchewan (SK) Yukon Territory (YT) Nunavut (NU)
Select a category for your GBS experience: *
-Unspecified-
Miscarriage
Stillbirth
Infant Death
GBS Survivor
Other
How far along was your pregnancy? *
Examples: 12 weeks, 30 weeks, full-term.
Were you tested for GBS? *
Don't know
Yes
No, considered GBS+ due to previous baby infected by GBS
No, considered GBS+ due to my urine culture results
No
If you were tested for GBS, what was the test result?
Not tested
Don't know
Positive
Negative
What was your treatment for GBS, if any?
-Unspecified-
IV anbiotics during labor and delivery
Alternative treatments (please explain details in your story)
Both of the above
None, my baby was miscarried or stillborn
No treatment
Date your baby was born, miscarried or stillborn:
-?- 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 -?- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -?- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Date your baby died, if not the same as above:
-?- 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 -?- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -?- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
In what specific ways did GBS harm your baby?(please note you can describe your GBS experience in detail later on this form)
Examples: preterm labor caused premature birth resulting in hearing loss,
chorioamnionitis, spent 3 days on ECMO, or meningitis
How do you share GBS information with others?
Examples: gave GBS brochures to all the pregnancy clinics in my town,
use GBS awareness postage stamps, etc.
Your first name: *
Your last name: *
Your email: *
(We require your email address only in case we need to contact you to clarify details before posting your story. GBSI will not share your email address with anyone.)
Enter your GBS story here (no size limit), or a link to your web site: *
You may attach a photo of your baby, if desired:
(64MB max.. if larger, email to info@gbs-intl.org)
(Pictures can help tell your GBS story, but please
be aware that images posted on websites can also be downloaded by viewers.)
What is three times six?: *