What state are you from?

1. What is your gender?

2. What is your age?

3. What is your relationship to the person you care for?

4. Do you have someone you could talk to if you needed emotional support or had a difficult decision to make?

5. Do you talk to close friends or relatives (in person or on the phone) at least once a week?

6. Do you belong to any community, volunteer groups or organizations?

7. Do you have any chronic illnesses (such as: diabetes, arthritis, high blood pressure, etc.)?

8. Have you ever been diagnosed with depression?

9. Did the person you were caring for receive hospice care before he/she died?

10. For how long?

10a. How close did you feel to the deceased?

10b. How dependent did you feel on the deceased?

10c. In the last two years have any of your friends, family members or pets passed away?

11. I am preoccupied with the thoughts of the death of person who I was caring for

12. I feel drawn to places and things associated with the person who I was caring for

13. I feel myself longing and yearning for the person who I was caring for

14. I feel lonely since the person that I was caring for passed away

15. I go out of my way to avoid reminders that the person that I was caring for is gone.

16. I feel like the future holds no meaning or purpose without the person that I was caring for

17. I feel I have become numb or detached since the death of the person that I was caring for

18. I feel stunned, dazed or shocked over the death of the person I was caring for

19. I feel disbelief over the death of the person that I was caring for

20. I feel that life is empty or meaningless with the person that I was caring for

21. It is difficult for me to imagine life being fulfilling without the person that I was caring for

22. I feel part of myself died along with the person that I was caring for

23. I feel that the death has changed my view of the world

24. I feel pain in the same area of my body, some of the same symptoms, or have assumed some of the behaviors/characteristics of the person that I was caring for before he/she died

25. I am bitter over the death of the person that I was caring for

26. You have experienced the above feelings for at least 2 months

27. I believe that my grief has resulted in impairment in my social, occupational or other areas of functioning

28. Would you like more information about grief or bereavement services?

29. Would you be interested in possibly being contacted as part of our future research being conducted by Yale School of Public Health and the John D. Thompson Hospice Institute for Training, Education and Research? If so, please enter you email address:

Research has identified 12 risk factors for major depression and poorer quality of life and adjustment for caregivers adjusting to the loss of a loved one. Your responses to this survey will tell you how many of these risk factors you have.

Thank you and Best Wishes