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

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* 1. Please provide the following:

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* 2. Preferred method of contact:

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* 3. Please provide the following.

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* 4. Organ(s) received:

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

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* 6. From whom did you receive an organ?

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* 7. Have you met your donor’s family?

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* 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.)

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

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

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* 11. Have you ever shared your story publicly?

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

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* 13. Media market closest to your home:

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

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

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

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

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* 18. In what cities did you compete?

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* 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.

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