2011 Donor Recognition Ceremony Evaluation Form

1.

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* 1. Your family's experience with organ/tissue/eye donation took place:

Within the last year

1-2 years ago

3-4 years ago

5-6 years ago

more than 6 years ago

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* 2. Do you think you would attend this event again in the future?

Yes

No

Maybe

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* 3. How accessible and helpful was the staff from Intermountain Donor Services?

	1. Least positive	2.	3.	4.	5. Most Positive	N/A
Staff Evaluation	Staff Evaluation 1. Least positive	Staff Evaluation 2.	Staff Evaluation 3.	Staff Evaluation 4.	Staff Evaluation 5. Most Positive	Staff Evaluation N/A

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* 4. How meaningful were the different aspects of this event?

	1. Least positive	2.	3.	4.	5. Most Positive	N/A
Tribute Video	Tribute Video 1. Least positive	Tribute Video 2.	Tribute Video 3.	Tribute Video 4.	Tribute Video 5. Most Positive	Tribute Video N/A
Donor Quilt	Donor Quilt 1. Least positive	Donor Quilt 2.	Donor Quilt 3.	Donor Quilt 4.	Donor Quilt 5. Most Positive	Donor Quilt N/A
Meeting other Families	Meeting other Families 1. Least positive	Meeting other Families 2.	Meeting other Families 3.	Meeting other Families 4.	Meeting other Families 5. Most Positive	Meeting other Families N/A
Reception	Reception 1. Least positive	Reception 2.	Reception 3.	Reception 4.	Reception 5. Most Positive	Reception N/A

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* 5. How meaningful or helpful were the speakers for this event?

	1. Least positive	2.	3.	4.	5. Most Positive
Master of Ceremonies	Master of Ceremonies 1. Least positive	Master of Ceremonies 2.	Master of Ceremonies 3.	Master of Ceremonies 4.	Master of Ceremonies 5. Most Positive
Donor family member	Donor family member 1. Least positive	Donor family member 2.	Donor family member 3.	Donor family member 4.	Donor family member 5. Most Positive
Transplant recipients	Transplant recipients 1. Least positive	Transplant recipients 2.	Transplant recipients 3.	Transplant recipients 4.	Transplant recipients 5. Most Positive

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* 6. Please rank:

	1. Least positive	2.	3.	4.	5. Most Positive
How meaningful was your experience on this day?	How meaningful was your experience on this day? 1. Least positive	How meaningful was your experience on this day? 2.	How meaningful was your experience on this day? 3.	How meaningful was your experience on this day? 4.	How meaningful was your experience on this day? 5. Most Positive

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* 7. Please describe what you felt was the most positive aspect of the ceremony:

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* 8. Additional comments or suggestions: