* 1. I am a:

* 2. I am presently a:

* 3. My Residency is/was

4. If a Fellow, I work in the:

* 5. In my career, the number of patients whom I have been directly in charge of his or her care at the time of death:

* 6. While in Medical School, I would rate the training I received to internally cope with the death of a patient who was under my care as:

* 7. While in Residency, I would rate the training I received to internally cope with the death of a patient who is under my care as:

If applicable, while in Fellowship, I would rate the training I received to internally cope with the death of a patient who is under my care as:

* 9. I feel I process the death of a patient in a healthy manner.

* 10. I am satisfied with the way I process the death of a patient.

* 11. I would like to receive further assistance on how to process the death of a patient.

* 12. There is someone in my workplace whose job responsibility includes helping me process the death of a patient.

13. If I answered "True" to #12, I feel comfortable approaching this person to help me process the death of a patient.

14. When a patient dies, I typically feel (check all that apply):

15. When a patient dies, I (check all that apply):

16. I have participated in the follow-up appointments related to patients who have died (check all that apply):

* 17. When a patient for whom I have recently cared for dies, I am able to provide quality care to other patients in the same day.

* 18. When a patient for whom I have recently cared for dies, I am able to provide quality care to other patients in the same week.