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Organ Donor Assessment

Thanks to the generosity of donors and their families, thousands of lives are saved, and quality of life is restored every year.

To ensure we are providing meaningful services for donor families, we are asking you to complete this questionnaire. The information you share is invaluable and will allow us to understand your experience with the donation process and LifeGift. The results will also help us offer sensitive care to future donors and their families.

Your Name:*
Your Loved One's Name:*
MM slash DD slash YYYY
What is your relationship to the donor? I am his/her/their:*
What inspired you to donate or support your loved one’s decision to donate? (Select all that apply)*

On a scale of 1-4, please rate the following experiences with the healthcare team from the hospital.
4-Strongly Agree, 3-Agree, 2-Somewhat Agree, 1-Disagree.

On a scale of 1-4, please rate your experience with the LifeGift staff member who discussed organ donation with your family.
4-Strongly Agree, 3-Agree, 2-Somewhat Agree, 1-Disagree.

When thinking about the first time someone spoke to you about a donation, which of the following phrases best indicates how you felt:*
When thinking about the length of the entire process from the donation conversation to the time your loved one went to the operating room, which of the following statements best indicates how you feel:*
Based on your experience, would you be supportive of donation in the future?*
What information and / or materials provided by LifeGift have been helpful to you?*
Please verify if you received the Donation Outcome and Support Packet with the following information: Donation Outcome Letter, Grief Booklet-Navigating Grief, Donor Certificate/LifeGift Dove*

If you requested follow-up or have questions, please provide your name and contact information below.

Name
Requested follow-up (please check all that apply)