Learning Disability Deaths 1 March 2020 onwards

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is being used to collect information in relation to the deaths of learning disabled people in the UK during the Covid19 pandemic. You do not need to use the person's real name but I (@GeorgeJulian) do need your name and email address and you need to have the permission of their next of kin to share this information with me. If you need help completing this form please email LearningDisabilityCovid@gmail.com Thank you.

Your Name *

Email *

Name of the person who died (use a pseudonym if you prefer) *

What was their sex? *

Female

Male

Prefer not to say

Required

What was their date of death? *

YYYY

How old were they? (Leave blank if unknown) *

Where did they die? *

In their usual residence (in the community)

At a residence they moved to for the duration of the pandemic (e.g. temporary return to family home)

In an acute hospital

In a secure hospital or ward (e.g. an assessment and treatment unit)

Other (please specify)

Whereabouts in the UK did the person usually live? Please supply the first half of the postcode. *

Was it suspected, or confirmed, that they had Covid19? *

Yes, confirmed with a test

Yes, suspected but not tested

No, did not have Covid19

Don't Know

Was their death referred to the coroner? *

Yes

Don't know

Would you like their death to be added to an online memorial map showing the deaths of learning disabled people during this time? *

Yes, just their name

Yes, their name and age

Yes, their name and photo (please email us a photo)

Yes, their name, age and photo (please email us a photo)

No, please do not share any individually identifiable information publicly

Required

Anything else that you think we should know

Please confirm that you understand that we are collecting this information to remember the lives and deaths of learning disabled people during the Covid19 pandemic, and you are happy for us to hold this data and share publicly in the manner you have chosen above *

Yes, I understand

Required

Please confirm that you have consulted with the deceased person's next of kin (if you are not them) and they are happy for you to share this information *

I am the person's next of kin, and consent to sharing this information

I am not the next of kin but I have their permission to share this information

I am not the next of kin and no other kin is known.

Required

Are you happy for someone to contact you to collect more information about the person and the care that they received? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms