Final Words Project - Submission Form
The Final Words Project is collecting stories about your loved one's "final" utterances for research and publication. We are interested in learning about the words that puzzled you or confused you as well as those that made sense to you or touched you in some way. Your submission will contribute to our better understanding the language of end of life. Thank you.

--------- International Visitors Please Note ---------

Submissions are welcome in ALL languages.

You can translate this form into other languages as follows:
* in Google's Chrome Browser - click the Translate button at the top.
* in Microsoft's Explorer or Edge Browser - click the Bing Translate option.
* in Apple's Safari Browser - download one of the Safari Translate Extensions.

--------- --------- --------- --------- --------- --------- ---------
Your Contact Info
We promise to keep your contact information *private*. We need it only so we can contact you about your submission.
Your Full Name: *
Notes on how and when is best to contact you, if needed: *
(We may wish to learn more about your story.)
Your Email Address: *
Your Phone #: *
Would you like to be added to the Final Words Project email list? *
Your Story
Your “final words” story: *
(This can be as brief or as detailed as you prefer.)
What did these words mean to you? *
(This can be as brief or as detailed as you prefer.)
Name of the person who spoke these words: *
(If you prefer, feel free to use a pseudonym or just say "anonymous".)
His/her relationship to you: *
I certify that this story is true: *
Background Information
When did this person speak these words? *
(This can be a date, a month and year, or an approximation.)
The circumstances and setting when they spoke: *
Who was present when the words were spoken? *
What was the person's condition at the time? *
Comments about the person's condition.
(optional)
How much time passed from the time of their words until they passed away? *
(Can be approximate.)
To the best of your recollection, was he/she on any medications? *
Permission to use this story:
Any comments you wish to make about our potential use of this story:
Do we have your permission to include this story in our research project? *
Do we have your permission to publish this story? (website, book, etc.) *
Please click "Submit" below ...
Thank you so much for sharing these final words.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.