Thank you for taking the time to tell us your story.
Please note that this form is confidential to the Child and Youth Mortality Review Committee. The form starts with asking you to name who died, then asks you what happened from your point of view. We hope it is easy to follow, but if you have any comments about improving it please let us know.

If you prefer, you can print a PDF version of the form, fill it out by hand and post it to:

Mortality Review Data Group
Department of Women's and Children's Health
University of Otago
PO Box 56
Dunedin 9054

Please mark the envelope 'private and confidential'.
When filling the online form please remember to click the SUBMIT button (at the end of the form) when you have answered all you can. You will then see a confirmation page and if you provided an email in the form, you will also receive a confirmation email.
Start online form now.