Survey

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Section A. About the person who died.

Was the person who died:

Male

Female

Other

I prefer not to say

What was your relationship to the person who died?

They were my:

Mother / Father

Brother / Sister

Son / Daughter

Spouse / Civil partner

Other family member

Friend

Other, please specify:

I prefer not to say

Where did they die?

In hospital

In a hospice

In their home

In a care home

Somewhere else (for example at the scene of an accident)

Don’t know

I prefer not to say

When did they die?

Less than 1 year ago

1 – 2 years ago

3 – 5 years ago

Don’t know

I prefer not to say

What was their age when they died?

Loss during pregnancy under 16 weeks

Loss during pregnancy over 16 weeks or Stillbirth

Under 5 years

5 - 18 years

19 - 24 years

25 - 34 years

35 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 - 84 years

85 - 94 years

95 years and over

Don’t know

I prefer not to say

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