First Name: Last Name: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Email: Phone: Name of deceased person: Relationship to participant: Cause of death: Date of death: Is there anything that would be helpful for us to know about the death in your family and your grief response? Emergency Contact Name: Emergency Contact Phone Number: Relationship to Emergency Contact: (2025) Race/Ethnicity Black, African, or African American East Asian or South Asian Hispanic or Latinx/a/o Indigenous / First Nations Middle Eastern or North African Native Hawiian or Other Pacific Islander White/Non-Latinx or Caucasian Other Multiple races Prefer not to answer (2025) Do you live in a rural area? (2025) Do you identify with any of the following? (2025) Has a family member or loved one died by suicide? (2025) TGRC has received funding to support families & individuals bereaved by COVID-19. Do you know someone who has died as a result of COVID-19? (2025) Is your family eligible for free school lunches, Medicaid, Healthy MT Kids, SNAP benefits, or other state or federal assistance programs? (2025) If YES, which programs?