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Know anyone who died after Dec 1, 2020
Please read these instructions carefully.

If you know the date of death of someone who died on or after December 1, 2020 FROM ANY CAUSE, please report it here.

You do not need to know any details beyond the name, relationship, age, and date of death.

Please don't report celebrity deaths, etc. Just deaths in YOUR circle (family, your friends), i.e., people you have had a conversation with at some point in time.

You can report as many deaths where you know the details as you want. It's up to you. Please start with the deaths whose details are most familiar to you (e.g., a family member where you can answer all the questions).

There are less than 20 questions, but only 4 are required. If you can answer all 20 questions, that's perfect. Skip the questions you don't know.

If you experienced multiple deaths, please use a separate form to record each death.

Don't guess. If you don't know the answer or none of the answers fit, just skip the question.
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Your email (won't be published; in case we need to contact you) *
Name of deceased (won't be published, we need for verification and to eliminate duplicates). Note: If you are a healthcare worker, you cannot legally provide this so please don't.
Your close relationship with the deceased. It should be someone you have had a conversation with. The deceased was my ... *
Sex of deceased
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Age at time of death *
Date of death (must be on or after Dec 1, 2020) *
MM
/
DD
/
YYYY
COVID vax status at time of death, e.g., Dose 1 means he had most recently received Dose 1. Do not guess. Leave blank if you don't know.
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If vaccinated, how many DAYS AFTER DOSE did the deceased die? (skip if not vaxed)
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Cause of death (check ALL that apply). If you don't know, skip this question.
Worsening of a pre-existing fatal condition? As usual, skip if you don't know
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Activity at time of death. Skip if you don't know.
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Died unexpectedly? Skip if you don't know.
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Number of comorbidities (conditions that put you at higher risk for dying such as over 75 years old, obesity, diabetes, heart disease, cancer, respiratory disease, high blood pressure, autoimmune disease, prion diseases, etc)
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Vaccine brand taken (the very FIRST shot). Leave empty if you don't know
Vaccine brand taken (the 2nd shot)
Vaccine brand taken (the 3rd shot)
Vaccine brand taken (the 4th shot)
Country where the death occurred
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Postal code of where deceased was currently residing at time of death. Leave blank if you don't know.
BONUS question: Do you think the vaccines are safe and effective? (leave blank if you aren't sure)
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Thank you so much! Anything else you would like us to know about this death?
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