Exit this survey Organ Donor Survey Question Title * 1. Are you on the NHS Organ Donor Register? Yes No Question Title * 2. If you are not on the NHS Organ Donor Register, would you be willing to sign up?(If you are already on the register, skip to question Five) Yes No Question Title * 3. If you are not on the register and you are unwilling to sign up, what are your reasons? Tick all that apply. Religious beliefs I don't like the thought of it I believe your body should be kept intact after you die I don't believe I am healthy enough Other, please state or add a comment on any of the above if you wish. Other (please specify) Question Title * 4. If you are not on the register but are willing to sign up, what would be the easiest way for you to sign up? Online on the NHS Organ Donor Website When Registering with a GP When Registering for a European Health Insurance Card At the Life Store in The Mall, Middlesbrough When I apply for a driving licence When applying for a Boots Advantage Card If you think there would be any easier ways to register your wishes, please state your ideas here Question Title * 5. If you are on the Organ Donor Register, what were your reasons for signing up? Tick all that apply. I just think that after I die, my organs will be no use to me anymore. The importance of Organ Donation was brought home to me when a friend/family member needed an organ. I like the idea that after I die, I could help someone else to go on living. I like the idea someone's quality of life could be improved from receiving an organ from me after my death. I think if I died in tragic circumstances, my family would find comfort in the idea my organs could help someone else live. If you wish to comment further on your views on signing up to the Organ Donor register, please do so here. Question Title * 6. If you are on the Organ Donor Register, or are willing to sign up, are you happy for: any/all of your organs or tissues to be donated, including corneas and all internal organs and tissues? Only certain organs that I have specified to be donated? Please add a comment on your choice if you wish Question Title * 7. Do you agree with the idea that everyone should be automatically included on the Organ Donor register with the ability to opt out if they wish? Yes No If you wish, you can give reasons for your answer. Question Title * 8. Have you discussed your wishes, whatever they are, with your family? Yes No Add a comment if you wish Question Title * 9. We are hoping to contact those who would be willing to share their views on Organ Donation. If you wish, please leave your details below. These will not be passed on to any third parties. Name: Address: Address 2: City/Town: Postal Code: Email Address: Phone Number: Done
