Transplant - Donor Family Information

 
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:
2. Preferred method of contact:
3. Donor Information:
4. Donor's age at donation:
5. Donor was a (check all that apply):
6. Date of donation:
7. Do you know the recipient of any of your loved-one's organs?
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.)
9. I would like to help promote (check as many as apply):
10. Have you ever shared your story publicly?
11. Indicate the types of media that you might be interested in doing:
12. Media market closest to your home:
13. Will you be coming to the Transplant Games?
14. Are any of the recipient's of your loved-one's organs competing in the Transplant Games in 2010 in Madison?
15. In what sport(s) will they compete?
16. Have you ever attended the Transplant Games before?
17. In what cities did you attend the Games?
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.
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