1. General Information

Thank you for participating in the MITSS Patient and Family Support Survey. This information will help better serve you and other patients and families who have experienced the emotional impact of an adverse medical event. This is a confidential survey.

* 1. Are you male or female?

* 2. Age?

* 3. How did you find MITSS?

* 4. What city/ state/ country do you live in?

* 5. If this is not the same location as where the event occured, please tell us the city/ state/ country where the event took place.