Transplant - Living Donor 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. Please provide the following.

Please provide the following. Current age:
Age at time of donation:

4. Organ(s) donated:

Organ(s) donated: Liver

Kidney

5. Date(s) of donation:

Date(s) of donation:

6. Donated organ to:

Donated organ to: Family member

Friend

Co-worker

Humanitarian/anonymous

7. Will your recipient be coming to the Transplant Games in 2010 in Madison?

Will your recipient be coming to the Transplant Games in 2010 in Madison? Yes

8. 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 Donation

9. Have you ever shared your story publicly?

Have you ever shared your story publicly? Yes

10. 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

11. 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):

12. Are you planning to participate in the Transplant Games in 2010 in Madison?

Are you planning to participate in the Transplant Games in 2010 in Madison? Yes

Undecided

13. Have you ever participated in the Transplant Games before?

Have you ever participated in the Transplant Games before? Yes

14. In what cities did you compete?

In what cities did you compete? 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):

15. 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.