Cause of death reporting form
If you have lost an HWV we would be grateful if you could complete this form. We are keen to monitor the causes of death in the breed.

Please note the following:
• This form should only be completed by the owner or with the owner's explicit permission. You do not need to be a member of the HWVA to submit the form.
• This is seperate to previous health surveys and no information has been transferred from these. We would encourage you to submit the information again if possible.
• The purpose of this form is to collect data. We are happy to share the data we compile but neither the dog or owners name will form part of the information shared.
• We may ask if we can get back in touch with you in certain circumstances for example to gleen further information about an emerging condition. If you do not wish to be contacted any further about your response, that is perfectly OK, please just tick the corresponding box on the form.

Email address *
Your name *
Your answer
Your dogs name *
Please use your dogs pedigree name to allow us to differentiate respondants
Your answer
Your dogs sires name
Your answer
Your dogs dams name
Your answer
Your dogs date of birth
If you don't know this use an approximate date and tick the box below
MM
/
DD
/
YYYY
Is this date of birth an estimate?
Leave empty if not
Date of death
MM
/
DD
/
YYYY
Age at death
Please answer in whole years (not rounding up)
Your answer
Please tell us about the cause of death. *
We have listed the most commonly reported causes of death below. Please tick what you consider the most relevent category and give further details in the space below this.
Required
Further information about the cause of death
Your answer
We will assume you are happy for us to contact you about this survey if necessary unless you tick the box below.
A copy of your responses will be emailed to the address you provided.
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