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Click for questionnaireHave you been affected by a pregnancy-related crash? Advocates for Auto Safety during Pregnancy works with “survivor advocates” to advance transportation safety for pregnant women and their babies. Survivor advocates have suffered the personal consequences of motor vehicle crashes while pregnant - either having personally survived a crash, being an involved relative or have had a fetus or baby lost or injured in a crash. 

If you are interested in working with us to educate medical providers, inform the public and the media, promote responsible and safer automobile designs and improve highway and auto safety for pregnant women, please fill out the story questionnaire. Your personal information will be kept confidential unless you consent to re-release of this information.

Thank you for your interest, your time and your willingness to share your story. It is through such stories that this hidden epidemic will become better known, understood and ultimately prevented in future generations.


Please read: Submitting this form indicates that you wish to be added to our Advocate Network and hereby give permission for your story to be told without any identifiers on this website. By becoming a member of this network, you may receive information regarding pertinent organization, publicity and safety issues that are relevant to your story. You may also receive requests to have your contact information forwarded to the media or other survivor advocates, but only with your additional permission.

For your privacy, no personal data are stored on this Webserver. Your information is forwarded automatically to a secure email inbox.

Your Story Questionnaire

Please provide us with the following information so that we may contact you in the future (optional).

What is your gender?

How old are you?

Your relationship to child in crash:





CRASH INFORMATION


From what main direction was the vehicle struck?

Did the police respond to the crash?


MOTHER's INFORMATION

Was the mother wearing a seat belt?

What seating position was the mother riding in during the crash?

If the vehicle had air bags, did they deploy?

Did the mother require any medical treatment?

Was the mother hospitalized right after the crash?

Not including the baby, was anyone killed?


BABY INFORMATION


Did the baby survive?


If the baby survived, were there any medically documented injuries to the baby? (describe)


If the baby died, what medical and trauma factors may have led to his or her death?

Please provide any other details of your story you feel are important:

How did you hear about our organization?

What might you like to do for the organization?

CONSENT

Would you be willing to consider talking to the media about your story? (Your contact information will not be forwarded to anyone without us contacting you first, in any case.)


Would you be willing to talk to individuals or families who have recently been impacted by a pregnancy related crash?


Click the submit button once when data entry is complete. It may take several seconds before the submission is processed and confirmed.


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AASP  


Knowing is not enough; we must apply. Willing is not enough; we must do - Goethe


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Copyright © 2004 Advocates for Auto Safety during Pregnancy (AASP)
Last modified: 06/21/04