Printable Lyme Disease Survey

from lds.htm
to fill it out via internet, use this link:
http://lymesupport.net/la/lds.htm
Home • Up • Printable Lyme Disease Survey • la/survey.pdf • Lyme Disease Survey Form

Do you have issues you would like responsible parties to address regarding Lyme disease (borelliosis) and other tick-borne illnesses?
Do you want to help educate others regarding these your concerns?

If so, please use the online survey below to express your concerns in relation to your experience. You may provide a video interview of your responses if desired.

If you would like to print and hand-fill out the survey or pass it on to your friends and neighbors, use the link that follows: http://lymesupport.com/la/index.htm or survey.pdf (186 kb; right click and "save target" for adobe reader) or survey.doc (70 kb, right click and "save target" for Word document)
We will also accept videotape presentations and emailed testimonies of your concerns. Just be sure and use the survey as a guideline for what to talk about. Please provide your contact information regardless what method you use to send us your results.
Please mail your results to this address:

TRISHA
c/o Nancy Berntsen
1017 Howe Ave
Shelton CT 06484

^{To contact us by email,
send email to:}
Nancy can be reached at (203) 924-9395
ABOUT US:
You will be submitting your survey results to Nancy Berntsen, founder of WCLDSG, Western CT Lyme Disease Support Group, a.k.a., "TRISHA," Tick-Related Illnesses Self-Help Alliance, which is a private Lyme disease support group.
My hope is to foster a better future for mankind regarding the impact of Lyme disease and other tick-borne illnesses. One of ways we might accomplish that is by presenting collective concerns of the citizens of Connecticut and elsewhere to local, state and/or federal authorities responsible for the health and welfare of it's citizens. Your input is most welcome by way of this survey!

Please provide the following contact information that applies to you.

Initials	________________________________________________________
*Full Name*	________________________________________________________
*Organization*	________________________________________________________
*Street address*	________________________________________________________
*Address (cont.)*	________________________________________________________
*City*	________________________________________________________
*State/Province*	________________________________________________________
*Zip/Postal code*	________________________________________________________
*Country*	________________________________________________________
*Work Phone*	________________________________________________________
*Home Phone*	________________________________________________________
*FAX*	________________________________________________________
*E-mail*	________________________________________________________
*Webpage URL*	________________________________________________________

Please describe yourself:

Month/year of birth	_________________________
Gender	Male Female

Select any of the following options that apply:

	1. I give my permission to utilize/print my survey results (items #2-7) in full or in part.
	2. I give permission to use my contact info (from #1) as necessary. I understand that my contact information will not be sold, given away or misused, and I will only be contacted if believed to be necessary.
	3. I request that any contact information from section #1 except my initials, town and state be withheld from any publication of survey results.
	4. I am willing to testify in person regarding my story/concerns in public (example: a public hearing) if I am available.
	5. I give permission to present my concerns in full or in part via videotape or other recording for investigative and/or educational purposes regarding problems with Lyme disease and other tick-borne illnesses.

The information I am providing below is about:
myself.
my child of whom I am a legal guardian.
OTHER:______________________________.
(Note: we will not knowingly use data for anyone other than you or your legal child without his or her consent.)

What are your biggest concerns about tick-borne illnesses?
(Select up to five you would like to elaborate on further in the survey)
____Inaccurate lab tests
____Diagnosis problems
____Treatment/cure issues
____Difficulty finding a qualifed health care practitioner
____Suppression of supportive research
____Insurance coverage issues
____Title 19 or Husky coverage issues
____Loss of time at job or school due to illness
____Lack of an standard for treatment for early or chronic infection .
____No acceptable standard for diagnosis
____Inaccurate reporting of cases of Lyme disease
____Tick control
____Safety of donor blood in blood banks
____Tick testing
____Persecution and/or censorship of particular doctors
____Over-reliance on faulty lab tests for diagnosis
____Incompetent doctors
____Disability issues
____Education issues
____Public health issues
____Vaccine issues
____Impact of family/marriage
____Impact on friendships
____Impact on job performance
____Financial burden
____Multiple family members infected with TBIs
____ Misuse of CDC criteria (used for reporting Lyme disease) to rule out Lyme disease even though clinical symptoms and history are strongly suggestive of Lyme disease
____Other concerns _________________________________________________________________________

Please discuss your concerns about Lyme disease and/or tickborne illnesses in relation to your experience(s).

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Please summarize your concerns or state any other information, questions, comments or suggestions you want to bring to the attention of the office of the Attorney General or other responsible parties.

Your signature_____________________________________ Date:___________________________

Submit form via US mail to address above.

Copyright Nancy Berntsen, TRISHA. Last revised: June 10, 2008

Copyright Nancy Berntsen, TRISHA.
Last revised: June 10, 2008