NACAC Blood Bank

Blood Drive Pre-Event Survey

If you have any questions about the upcoming Blood Drive, survey questions, or have interest in helping to plan or prepare educational materials for this event, please e-mail SocialAction@nacacdst.org

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* 1. Have you donated blood in the past?

Yes

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* 2. Do you know your blood type?

Yes

Not Sure

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* 3. Have you faced any obstacles in donating blood? Please check all that apply.

No obstacles

High Blood Pressure

Age

Weight

Other health condition

Fear of needles

Tatoos/Piercings

Pain or discomfort

Dizziness/weakness

Other (please specify)

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* 4. If able to donate, what information or incentive would encourage you to participate?

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* 5. Do you have any concerns about donating blood? If so, please specify all that apply.

No concerns

Uncertain about how my blood will be used

Concerned about other genetic data being captured through my blood

Concerned that other medical information (i.e. pre-existing conditions) will be ascertained, disclosed and/or shared

Reluctant due to past history with medical experimentation

Distrustful of medical institutions overall

Other (please specify)

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* 6. Would you be willing to share information about our Chapter's Blood Drive with your networks?

Yes

Comment:

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* 7. Are you aware of organizations, individuals or groups with whom we should be sharing information about our Blood Drive? If so, please provide name and contact information.

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* 8. Prior to hearing about the following during the recent Chapter Meeting, did you know that.....

	Yes	No
1/2 of the African American population has type O positive blood?	1/2 of the African American population has type O positive blood? Yes	1/2 of the African American population has type O positive blood? No
Type O positive blood is the most transfused blood type in the U.S.?	Type O positive blood is the most transfused blood type in the U.S.? Yes	Type O positive blood is the most transfused blood type in the U.S.? No
Type O positive blood is the first type to run out during a shortage due to high demand?	Type O positive blood is the first type to run out during a shortage due to high demand? Yes	Type O positive blood is the first type to run out during a shortage due to high demand? No
There is is critical need for Type O donors of all backgrounds?	There is is critical need for Type O donors of all backgrounds? Yes	There is is critical need for Type O donors of all backgrounds? No
African Americans represent only 3% of all blood donors in the U.S.?	African Americans represent only 3% of all blood donors in the U.S.? Yes	African Americans represent only 3% of all blood donors in the U.S.? No

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* 9. What is the likelihood that sharing information like that presented above would influence African American participation in the Blood Drive?

Very likely

Likely

Neither likely nor unlikely

Unlikely

Very unlikely

Other (please specify)

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* 10. In leading up to the Chapter's Blood Drive, what educational topics do you feel would be helpful to present?

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* 11. Do you have ideas about possible locations to hold a Blood Drive during the month of May? If so, please indicate below.

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* 12. If the date and time are convenient for you, do you intend to participate?

Maybe

Yes