Transplant - Donor Family Information Survey

Note: The information gathered through this survey is for UW Health use only and will not be shared nor sold to anyone.

1. Please provide the following:

Please provide the following: First name:
Last name:
Street address:
City:
State:
Home phone:
Mobile phone:
Work phone:
e-Mail address:

2. Preferred method of contact:

Preferred method of contact: Home phone

Mobile phone

Work phone

e-Mail

3. Donor Information:

Donor Information: Donor's first name:
Donor's last name:

4. Donor's age at donation:

Donor's age at donation:

5. Donor was a (check all that apply):

Donor was a (check all that apply): Organ donor

Tissue donor

Eye donor

6. Date of donation:

Date of donation:

7. Do you know the recipient of any of your loved-one's organs?

Do you know the recipient of any of your loved-one's organs? Yes, we have met in person.

Yes, we have exchanged personal information and connected directly with each other either via letter, email and/or phone, but haven't met in person yet.

Yes, we have exchanged letters but I don't know their actual name or address (just corresponding anonymously through the OPO).

I have sent letters to our recipient(s) but haven't heard back yet

No - I haven't tried to communicate with our recipient(s).

8. If you have met the recipients of your loved-one’s organs in person, please list their name and the organ(s) they received. (Note, a similar survey was sent to all UW Health transplant recipients. This question allows us to use this data to quickly match donors/recipients if a donor/recipient media opportunity arises.)

If you have met the recipients of your loved-one’s organs in person, please list their name and the organ(s) they received. (Note, a similar survey was sent to all UW Health transplant recipients. This question allows us to use this data to quickly match donors/recipients if a donor/recipient media opportunity arises.)

9. I would like to help promote (check as many as apply):

I would like to help promote (check as many as apply): New Wisconsin Donor Registry

2010 Transplant Games

Organ, Tissue and Eye Donation

10. Have you ever shared your story publicly?

Have you ever shared your story publicly? Yes

11. Indicate the types of media that you might be interested in doing:

Indicate the types of media that you might be interested in doing: TV (live)

TV (taped)

Radio

Print (newspaper, magazines, newsletters, web)

Video story (taped)

Speaking engagements

Press conference

12. Media market closest to your home:

Media market closest to your home: Milwaukee

Madison

Wausau

Eau Claire

La Crosse

Green Bay

Appleton

Other (please specify):

13. Will you be coming to the Transplant Games?

Will you be coming to the Transplant Games? Yes

14. Are any of the recipient's of your loved-one's organs competing in the Transplant Games in 2010 in Madison?

Are any of the recipient's of your loved-one's organs competing in the Transplant Games in 2010 in Madison? Yes

Don't know

15. In what sport(s) will they compete?

In what sport(s) will they compete? Badminton

Ballroom dancing

Basketball

Bowling

Cycling

Golf

Racquetball

5k run/walk

Swimming

Table Tennis

Tennis

Track and Field

Volleyball

Not sure

16. Have you ever attended the Transplant Games before?

Have you ever attended the Transplant Games before? Yes

17. In what cities did you attend the Games?

In what cities did you attend the Games? 1990 Indianapolis

1992 Los Angles

1994 Atlanta

1996 Salt Lake City

1998 Columbus

2000 Orlando

2002 Orlando

2004 Minneapolis

2006 Louisville

2008 Pittsburgh

World games (list location and year):

18. Please share any additional comments, or unusual circumstances that might be of interest to the media or the general public as we work to promote the Donor Registry, Transplant Games and organ donation.

Please share any additional comments, or unusual circumstances that might be of interest to the media or the general public as we work to promote the Donor Registry, Transplant Games and organ donation.