This survey will be used to help parents make informed choices about the funeral home they select for their baby.  Please provide your contact information so parents may contact you.  

Thank you for participating and for caring about families who have lost a baby to stillbirth.  Please make sure this information is updated annually.

Funeral Home:
Name and title:
Phone:
Address:
City
State:
Select State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MN MO MS MT ND NC NE NH NA NJ NM NY NV OH OK OR PA RI SC SD TN UT VI VT WA WI WV WY
Zip:
Do you provide funeral services for infants and/or little miscarried babies?
Yes No
Please Explain.
Will you work with a hospital to help the parent have their baby at home for a period of time, if they wish, under your direction?  (This requires appropriate forms, offering to let the family drive their own baby home, making sure the baby gets back to your funeral home, ect.)
Yes No
Please Explain.
Do you encourage both parents to discuss the services you offer and what they wish to do rather than working with a family member or only one parent?
Yes No
Please Explain.
Do you provide an opportunity for the family to dress, see, hold, ect. the baby prior to the service?
Yes No
Do you encourage the family to do this and tell them why?
Yes No
Do you have a rocking char available?
Yes No
Do you provide literature and/or direction to assists in writing an obituary and planning the service that is rocking char available?
Yes No
Do you provide the family private time with the baby? (including other children)
Yes No
Do you take pictures and/or encourage the family to take pictures/videos of their baby?
Yes No
How long after you receive the baby's body do you want/need to have the service?
Yes No
Do you encourage the family to have a viewing time to help make the baby real for the rest of the family who may not have met her/him?
Yes No
Do you allow/encourage families to have the service in there home, at their church, as well as in your funeral home chapel?
Yes No
Do you work through or with any particular cemetery?
Yes No
Are there any other comments you want included about your Funeral Home or the services you provide?
Yes No
What options are available for infant funerals and what are the price ranges?
under 20 weeks gestational?    over 20 weeks?
Do you provide free or relatively inexpensive services for infants if parents have financial hardship?
Yes No
List your prices for this year.
Please note: It is understood that your prices my be approximate for this year.  Please attempt to update this survey annually.  This will help us keep your page up to date. Thank you.
This survey for was create by Sherokee Ilse and Suson Martenex Erling. ©1982/2008
Survey available through Wintergreen Press, Inc. www.wintergreenpress.com