Name*
First
Last
Address
What is your gender?* -Select- Male Female I prefer to self-describe
Age range* Select Under 18 18-24 years old 25-34 years old 35-44 years old 45-54 years old Over 55
Please choose one option that best describes your ethnic group or background
White Mixed / Multiple ethnic groups Asian / Asian British Black / African / Caribbean / Black British Other ethnic group What is your relationship with the child who died?* - Select- Mother Father Grandfather Grandmother Sibling Aunt Uncle Other- please specify
Which of these most closely describes your baby or young child's cause of death?* -Select- SIDS - Sudden infant death syndrome SUDC - sudden unexplained death in childhood A stillbirth A neonatal death An illness or genetic condition An accident Cause is not yet known (awaiting post mortem results) Other (please tell us)
Have you used the LT bereavement service, including CONI support, before?* -Select- Yes No
If Yes, please specify which service Select Helpline Online Bereavement Support Group Befriending service CONI Programme
Volunteering as a Bereaved Families Panel member Please note this is not a support group and we ask you are at least 2 years bereaved and feel comfortable talking about bereavement without it becoming a trigger for you.
The commitment of the Bereaved Families Panel is to take part in 3 meetings a year (online) with ad hoc requests for help with resources, campaigns, consultation via email as and when.
What would you like to get from the Bereaved Families members panel?* Select Friendship / part of a community Helping to shapes services for future families Other
We are always looking for families to be part of our film campaigns. Would you like to be involved?* Select Yes No Maybe
Bereaved Families Panel Code of Conduct
Every member of the Bereaved Families Panel must: 1. Treat each other as an individual.
2. Support each member’s own individual choice about their own involvement within the Bereaved Families Panel.
3. Respect each person’s personal views and wishes.
4. Respect and maintain the dignity and privacy of members of the Bereaved Families Panel.
5. Respect diversity and different cultures and values and experiences of all members of the Bereaved Families Panel.
6. Be honest and trustworthy.
7. Communicate in an appropriate, open, accurate and straightforward way whilst making sure their actions, opinions and/or behaviour does not affect themselves or others in a negative way.
8. Be reliable, dependable and honour commitments, agreements and arrangements and, when it is not possible to do so, let the support team know.
9. Declare issues that might create conflicts of interest.
10. Strive to support the Lullaby Trust to the best of your ability and for the time indicated when you initially signed up, unless otherwise indicated to the Support Team.
Our promise to you as the professionals involved in the Bereaved Families Panel : 1. We will respect and, where appropriate, promote your individual views and wishes, working openly and co-operatively with all members.
2. We will promote equal opportunities for all members.
3. We will maintain confidentiality of all personal information. All information about you will be held in accordance with our Privacy Policy. See our privacy policy on our website for how we collect, use and look after personal information at https://www.lullabytrust.org.uk/privacy-cookies
4. We will respect all responses and remain impartial and non-judgemental whilst clearly explaining policies about confidentiality, the breaking of confidentiality, and the reporting of dangerous, abusive, discriminatory or exploitative behaviour. We will not tolerate abusive or inappropriate behaviour or language being used within the group; you may be asked to leave the group.
5. We will uphold public trust and confidence in the Bereaved Families Panel by acting in a lawful, safe and effective way.
6. We will be accountable for maintaining and improving the quality of the Bereaved Families Panel work.
7. We will protect the rights and promote the interests of all members, taking compliments and complaints seriously and responding to them by passing them to the appropriate person.
8. We will strive to establish and maintain the trust and confidence of all members.
By agreeing, you are confirming that you: • Will abide by ‘Bereaved Families Panel Code of Practice'
• Understand the role and responsibilities of the Support Team staff involved with the Bereaved Families Panel
Do you agree with the Bereaved Families Panel Code of Practice?* Select Yes, I agree No, I don't agree
Keeping in touch Text message* -Select- Yes No