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* 1. Who died in your first personal experience with death?

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* 2. When you were a child, how was death or dying talked about in your family?

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* 3. What does death mean to you?

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* 4. What about your own death concerns you most?

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* 5. What about the process of dying concerns you most?

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* 6. How large a role has religion played in your attitude toward death?

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* 7. If you were told that you had a limited time to live, how would you want to spend your time until you died?

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* 8. If or when you are married or have a long-term partner, would you prefer to outlive your spouse/partner?

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* 9. If you had a choice, what kind of death would you prefer?

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* 10. What is one thing you would want to say to someone special before you die?

Thank you for completing the survey.  If you have another minute to share a bit of information about yourself, it will help us make sure we are reaching our entire community.  

Gracias por completar la encuesta. Nos ayudará a asegurarnos de que estamos llegando a toda nuestra comunidad, si tiene un minuto para compartir un poco de información sobre usted.

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* 11. I most identify as:
    Me identifico como:

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* 12. My age range is:
    Mi rango de edad es:

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* 13. The category that best describes me:
      La categoría que mejor me describe:

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* 14. My home zip code is:
     El código postal de mi casa es:

If you have any questions or comments please call the End of Life Care Partnership, Senior Program Manager at 520-903-3911 or email EOLCP@unitedwaytucson.org.  

Si tiene alguna pregunta o comentario, por favor llame al Manejador del Programa Senior de Fin de Vida al 520-903-3911 o envíe un correo electrónico a EOLCP@unitedwaytucson.org.


The Center for Healthcare Decisions developed this questionnaire, based in part on Edwin Schneidman's "You and Death: An Exercise."

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