M.A.M.A. Entry Form

We are building a world-wide database to track professional accusers!
         
It is not required that you fill out all information below. By asking specific questions, it better enables us to supply you with  information which might be pertinent to your case, while also providing us with uniform statistical   information to better educate the media, attorneys and researchers. Only through united efforts will the true face of this diagnosis be revealed. If more than one child  is effected, please resubmit Child Information for each additional child.

Your Information
Name
Address
City State   Zip
Phone Fax Country
Marital status married   single seperated divorced remarried
     engaged widowed
Occupation(s)
Number of children: total pregnancies  living  miscarriage  multiples
died       date of death   age
autopsy? yes  no     Repoted cause of death:
Ethnic Background: White  Asian American  Native American  Hispanic
African American  other
 

Child Information
Name
Birthdate               male    female
(check all that apply) birth  adopted   foster  multiple birth  other 
Primary Diagnosis
Secondary Disability or Condition
   When was the primary disorder diagnosed ? before birth  at birth       at the age of
Apgar Score at birth /          birth weight
Length of pregnancy weeks (40 weeks is normal)
 

 

 Status of Case
Date Petition Filed Child(ren) Removed from custody? yes  no 
Placed in: Foster care supportive family member  accusing famly member
DHS custody/hospital bound
Date removed:             Date returned
Case was/is in child dependency court   criminal court
Initial Report made by: MD  CPS/DHS  ex-husband  hospital social worker 
school   mental health professional  insurance company  other
If report made by an MD specify specialty:
(general pediatrics, gastroenterology, neurology,etc)
Represented by: a public defender   court appointed  privately hired atty.  self
If case resolved: date resolved
Resolved by: mutual consent   management order  dismissed by judge 
parental rights severed   other    
Please specify the primary condition which you are accused of feigning or inducingand by what means:

 
MSBP expert(s) used by the prosecution:
Has a civil suit been filed? yes   no   planned after case settled
Court Repoter used for hearing? yes   no
Household income   at time of accusation: below $20,000 $20,000-$30,000 $30,000-$40,000 
$40,000-50,000      above $50,000
Mother's Education: (indicate years completed) high school  college  trade school 
Major    Minor
Father's Education: (indicate years completed) high school  college  trade school 
Major    Minor
   
 

 

                           
Your Accusers' Information
Doctor(s)
Doctor(s)
Hospital
other (specify)
Expert(s)

Any Professionals You Would Recommend (please specify specialty & phone)
Doctor(s)
Doctor(s)
Lawyer(s)
Other
Please Check All that Apply:
I would like to talk to other parents who have been accused by the same hospital or physician.
I would like to talk to other parents whose child has a similar condition as mine.
You may release this information for research statistics of MSBP accusations, with all identifying information removed.
I am willing to speak with members of the press.
I would like to join your listserv (bulletin board delivered privately through email) for parents only accused of MSBP.
Please do not release the above information to anyone!

Additional Comments

                                              

Please hit submit once (for additional children press reset and fill out only Child Information)


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M.A.M.A.
1407 Ranch Dr. Pvt.
Senatobia, MS 38668

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Mothers Against MSBP Allegations