End-of-Life Planning Survey
Please complete this survey to help us understand your end-of-life planning preferences and contacts. All responses are confidential and no sensitive personal, medical, or financial information is collected.
What is your current status regarding end-of-life planning?
*
I have a comprehensive plan in place
I have started planning but it is incomplete
I have not started planning yet
Prefer not to say
How important is it to you to have your end-of-life wishes documented?
*
Not important
1
2
3
4
Extremely important
5
1 is Not important, 5 is Extremely important
Do you have a designated person to handle your affairs?
*
Yes
No
Not sure
Please provide the name of your designated contact (if any).
What are your preferences regarding funeral or memorial arrangements?
Have you communicated your end-of-life wishes to your family or loved ones?
*
Yes, fully
Partially
No
How confident do you feel about your current end-of-life plans?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Do you wish to be an organ or tissue donor?
*
Yes
No
Undecided
Who should be contacted first in case of an emergency?
*
Is there anything else you would like to share about your end-of-life planning preferences?
Submit
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