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Shaping Bereavement Care

RESPONDENT INFORMATION FORM

Please Note this form must be returned with your response to ensure that we handle your response appropriately

1. Name/Organisation

Organisation Name

Title Mr

Ms

Mrs

Miss

Dr

Please tick as appropriate

Surname

Forename

2. Postal Address

Postcode

Phone

Email

3. Permissions - I am responding as…

Individual /

Group/Organisation

Please tick as appropriate

(a)

Do you agree to your response being made available to the public (in Scottish Government library and/or on the Scottish Government web site)?

(c)

The name and address of your organisation will be made available to the public (in the Scottish Government library and/or on the Scottish Government web site).

Please tick as appropriate

Yes

No

(b)

Where confidentiality is not requested, we will make your responses available to the public on the following basis Please tick ONE of the following boxes

Are you content for your response to be made available?

Please tick as appropriate

Yes

No

Yes, make my response, name and address all available

or

Yes, make my response available, but not my name and address

or

Yes, make my response and name available, but not my address

(d)

We will share your response internally with other Scottish Government policy teams who may be addressing the issues you discuss. They may wish to contact you again in the future, but we require your permission to do so. Are you content for Scottish Government to contact you again in relation to this consultation exercise?

Please tick as appropriate

Yes

No

Shaping Bereavement Care 58

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