Transplant - Transplant Recipient 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 transplant(s):

4. Organ(s) received:

Organ(s) received: Heart

Lung(s)

Liver

Kidney

Pancreas

Intestine

Combined organ transplant

5. Date(s) of transplant(s):

Date(s) of transplant(s):

6. From whom did you receive an organ?

From whom did you receive an organ? Family member

Friend

Co-worker

Directed donation

Humanitarian/anonymous

Deceased donor

7. Have you met your donor’s family?

Have you met your donor’s family? 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 my donor’s family but haven't heard back yet

No, I haven't tried to communicate with my donor’s family.

8. If you have met your donor’s family in person, please list their name(s).

(Note: a similar survey was sent to all UW Health donor families. This question allows us to use this data to quickly match donors/recipients if a donor/recipient media opportunity arises.)

If you have met your donor’s family in person, please list their name(s). (Note: a similar survey was sent to all UW Health donor families. This question allows us to use this data to quickly match donors/recipients if a donor/recipient media opportunity arises.)

9. Will your donor be coming to the Transplant Games?

Will your donor be coming to the Transplant Games? Yes

10. 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

11. Have you ever shared your story publicly?

Have you ever shared your story publicly? Yes

12. 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

13. 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):

14. Are you planning to attend the Transplant Games in 2010 in Madison?

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

Undecided

15. Are you competing in the Transplant Games in 2010 in Madison?

Are you competing in the Transplant Games in 2010 in Madison? Yes

Undecided

16. In what sport(s) will you compete?

In what sport(s) will you compete? Badminton

Ballroom dancing

Basektball

Bowling

Cycling

Golf

Racquetball

5k run/walk

Swimming

Table Tennis

Tennis

Track and Field

Volleyball

17. Have you ever competed in the Transplant Games before?

Have you ever competed in the Transplant Games before? Yes

18. 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):

19. 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.

Transplant - Transplant Recipient Information