| Deceased Data |
| Name of person who died |
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| Relationship to you |
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| Age |
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| Date of birth |
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| Date of death |
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| Nature of death |
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Write a few brief sentences to
describe your loved one. (Examples of information you may include would
be: What did he or she like best "to do" in life? What will you always
remember about him or her? How would a friend or relative describe this
person?) |
| Survivor Data |
| Your Name |
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| Address |
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| City |
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| State |
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| Zip |
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| Phone |
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| e-mail address |
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| |
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| Was this data collection form completed by you and does it reflect your thoughts to the
best of your ability?
YesNo |
| If not, by whom
was it completed? |
| Permission to print name/city/state in IndexYes
No |
| Permission to print initials/city/state in book
Yes
No |
|
Prefer anonymity, but incident may be used as an example |
| |
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Please answer as many of the questions below that you feel comfortable with. These
questions give me a better opportunity of understanding your grief and special loss. |
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1. Describe the events that led up to
the sudden death of your loved one. |
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2. How were you notified about his or
her death? (If you were present, briefly explain.) |
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3. What was your immediate reaction
or thought? |
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4. How did the media (radio,
television, and/or newspapers) handle the death, if you were exposed to
media? (sensitive or insensitive to family and situation) |
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5. In what manner did the funeral
directors assist you? Was this a positive or negative experience
considering the unexpected circumstances? |
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6. How helpful was your clergy in
assisting your with your unanswered questions or general need for
support? Give examples, if possible. |
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7. How did the community respond to
your loss and period of mourning? (church, workplace, school, social
clubs, neighbors etc.) |
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8. Describe any feelings of anger,
rage, un-forgiveness, and revenge that may have accompanied your loss—if
this was the situation. How did you manage these feelings? Describe your
initial feelings and describe how you were able to reconcile with these
feelings. |
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9. How did relationships change with
your spouse, your friends, your co-workers or your family as a result of
the loss? |
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10. Months later, how would you say
that this sudden death impacted your life most? |
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11. Did you experience any
"survivor’s guilt"? Explain the nature of your "guilt." (Survivor’s
guilt is common in accidental deaths in which you could also have died
but survived. And in situations in which a child dies before his or her
parents. This is also common when issues are unresolved at the time of a
death.) |
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12. What special losses have you
experienced as a result of this sudden death?
(Example: loss of dreams, grandchildren) |
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13. Did you experience problems as a
result of the loss that changed your life in other ways like: alcohol or
drug dependency, divorce or separation, or depression. How have you
managed that? |
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14. How did this sudden death affect
your spirituality or belief system?
(i.e. faith stronger or weaker, purpose for living, values or ethics,
thoughts about the inevitability of death. ) |
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15. Has there been a "turning point"
in your grief that helped you accept the tragedy and begin rebuilding
your life? If so, describe what has occurred. |
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16. Is there anything else that you
feel is important for others to understand about the sudden death
experience? Please comment. |
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17. If your loved one was the victim
of homicide, describe the impact of working through the judicial system?
How did this affect your ability to heal? |
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18. What social stigmas complicated
your freedom to grief or your ability to heal? |
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19. What unanswered questions
bothered you during your period of grief? |
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20. How did you get beyond having to
know the answers? |
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You may also mail or fax this
Information to:
Wings
Nan Zastrow
PO Box 1051
Wausau, WI 54402-1051
Phone or FAX (715) 845-3424
wings1@charter.net |