Family Factsheet for Media
If you'd be willing to speak with the media about your experience of group B Strep, please complete and submit this form.

Please give as much detail as you can - we try to match the media's requirements as closely as possible to ensure neither your nor their time is wasted. If you need more space, please fill in what you can, then send a separate email with the additional information to us at headed "Additional Information for Family Factsheet for Media".

Telling our stories of how group B Strep has affected us - whether it's during pregnancy, during the labour and delivery, or after our baby was born - is hugely powerful and brings home the reason why awareness is so important. Thank you so much for being willing to do this.

PLEASE NOTE: We will not share your contact details with anyone without your permission. Completing the form indicates you are willing to speak to the media in principle (you're not authorising us to share your information - that comes later). Once you've submitted the form, we will get in touch with you.

What is your first name? *
Your answer
What is your surname? *
Your answer
Your address *
Please include the postcode - media always need to know where you live (at least town & postcode)
Your answer
Your home phone number
Please include the STD code
Your answer
Your mobile phone number *
Your answer
Your email address *
Your answer
Your year of birth
Optional - publications usually want to know this
Your answer
Your occupation
Optional - again publications usually want to know this
Your answer
Your Pregnancy and Your Baby
From here, we're asking for information about the pregnancy and baby who would feature in any media story.

There'll be space at the end for you to add in extra information that we haven't specifically asked for.

Your baby's name
The name of your baby who was affected by group B Strep
Your answer
Your baby's date of birth
Please include the day, month, and year
Your answer
Your baby's gestation
How many weeks' pregnant you were when your baby was born?
Your answer
You baby's gender
Male or female
How was the pregnancy generally?
Had you heard about group B Strep before you gave birth?
Did you have a test for group B Strep during this pregnancy?
Did you know that you could be tested for group B Strep carriage in pregnancy?
If you had a test for group B Strep during your pregnancy, what was the result?
Do you think all pregnant women should be offered a free GBS test as part of their NHS care?
How has GBS affected you and/or the whole family?
Your answer
Were there any risk factors present for group B Strep infection developing in your baby?
There are a number of situations which can arise during pregnancy and the birth itself which increase the likelihood of the newborn baby developing group B Strep infection. Please indicate any or all that were present.
What sort of delivery did you have?
Where did you give birth?
Were you given antibiotics during your pregnancy, labour or after the baby was born?
What happened to your baby once s/he was born?
Your answer
When was group B Strep first mentioned to you?
Why was the issue of group B Strep raised with you?
If you can also tell us who mentioned it to you, what they said and how you felt, that would be helpful
Your answer
Did your baby have a confirmed group B Strep infection?
If you can also tell us how it was diagnosed, whether it was septicaemia, pneumonia, meningitis or another presentation of GBS infection, that would be helpful
Your answer
How old was your baby when their group B Strep infection was diagnosed?
Your answer
How long did your baby stay in hospital for?
Your answer
Additional Information
Clearly, we won't have asked you everything! Please let us know the answers to the questions we should have asked, but didn't.
Other information:
Please include anything else you think would be relevant here, including anything the media might find of particular interest. Please also tell us the names and dates of birth of any other children you have.
Your answer
Are you willing to be photographed for an article? *
Some publications will send out a photographer, many won't. If you're able to send us a photo that you'd be happy for us to use (we won't share it without your permission), please send it to
If your story has appeared in the press, please give details here
Ideally, the name of publication and the date on which your story appeared
Your answer
How would you like us to contact you about this?
Please indicate whether you would prefer us to contact you on your home phone, your mobile, or by email:
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.