Supplemental Table 1: Survey Instrument
Survey on Organ Donation
Organ Donor Status
Have you thought about organ donation before today?
Yes
No
Which of the following best describes you:
I do not believe I can register as an organ donor for personal reasons
I am a registered organ donor.
I would like to become an organ donor but have not registered.
I am considering becoming a donor but need more time to think about it.
I do not plan on becoming an organ donor.
If you are a registered organ donor, when did you register?
Within the last month
Within the last year
Over a year ago
If you would like to become an organ donor or are considering becoming an organ donor, have
you talked to your family about organ donation?
Yes
No
Before today, were you aware you can register to be an organ donor online?
Yes
No
The best way to provide organ donation information to you is through (please select all that
apply):
the Internet
A family member or friend
Displays in a public place
An organ donation
(billboards, grocery store,
representative in a public place
physician’s office, Walmart, etc. )
(grocery store, health fair, sporting
Pamphlets
event, etc.)
Your physician
Other: ___________________
The most convenient method for me to register as an organ donor would be:
through mailing in a paper form
through a live organ donation representative
through an online form
at the DMV
over the phone
Other: ____________________
Knowledge and Perception of Organ Donation
Please check true or false for the following statements about organ donation.
True
False
1. The number of organ and tissue donors is going up significantly every year
2. One organ and tissue donor can help over 75 patients in need
3. Most transplant patients live longer than 5 years after receiving their transplants
4. Organ donation prevents an open-casket funeral
5. The transplant waiting system is based on your race and income
6. A person who has been declared ‘brain dead’ but has a beating heart still has a small chance
of recovering
7. Shortage of organ donors is a major problem
Please check the degree to which you agree or disagree with the following statements about
donating organs after death.
Strongly
Disagree Neutral
disagree
My current state of health is not good enough to qualify me as an
organ donor
There are no drawbacks for me to sign up to be an organ donor
It is important to be buried or cremated with organs intact
I do not know enough about organ donation
Organ donation is consistent with my moral beliefs
Donated organs are allocated fairly
Organ donation is against my religious beliefs
Doctors would not try as hard to save me if they knew I was an
organ donor
Registering to become an organ donor is a good thing to do
Doctors may take my organs when I still have a chance for
recovery
Being an organ donor is important given the national organ
shortage
I am concerned that my organs might go to someone who does not
deserve them
I don’t know how I feel about organ donation
Agree
Strongly
Agree
Degree of Association with Transplant Recipient or Donor
Do you know anyone who has donated, needed or received an organ for the purpose of transplant
surgery?
Yes, please answer the questions on this page.
No, please skip to the next page.
If yes, what is your degree of relationship to the individual?
Self
Do you know anyone who has
donated an organ for the purpose of
transplant surgery as a deceased or
living donor?
Do you know anyone who has
needed an organ transplant?
1st degree
Relative
2nd degree
Relative
(sibling,
parent, child)
(grandparent,
aunt, uncle,
grandchild)
Partner/
Spouse
Friend
Other:
________
Yes
No
________
Yes
(if you answered yes, please answer questions 1+2 below)
No
Are you now or have you been the
primary support person (individual
helping the transplant candidate
throughout the transplant
evaluation, time of surgery, and
months following transplant) for
anyone needing a transplant?
________
Yes
(if you answered yes, please answer questions 3+4 below)
No
1. If you know anyone who has needed or received a transplant, how has that knowledge changed
your willingness to register as an organ donor?
1
Less likely to Donate
2
3
4
5
More likely to donate
2. If you know anyone who has needed or received a transplant, what is that individual’s current
status?
Currently on or planning on getting on the waitlist
Died while waiting for a transplant
Received transplant
Received transplant but needs retransplant
Other:
3. If you are a caregiver for an individual who needs or has needed a transplant, have you
discussed the topic of organ donation with that individual?
Yes
No
4. If you are a caregiver for an individual who needs or has needed a transplant, how many hours
in a typical week do you devote to caring for that individual?
<8 hours
8-20 hours
20-40 hours
>40 hours
Demographics
Age:
Gender:
Male
Female
Race/Ethnicity (check all that apply):
Caucasian
Black/African American
Hispanic/Latino
Asian/Pacific Islander
American Indian/Native American
Other:
Is English your primary language?
Yes
No
If not, what is your primary language? ______________________
Education (highest level completed?):
Grade school or less
High School
Some college
College graduate
Marital Status:
Married/Partnered
Single
How many children do you have?
None
1-2
3-4
>5
If you have children, how many are currently under the age of 18?
None
1-2
3-4
Do you have a driver’s license or a state ID?
>5
Yes
Do you attend religious services regularly?
Are you a professional health care provider?
No
Yes
Yes
No
No
What is your county of residence? ______________________________
Thank you for completing this survey, please let us know of any general feedback or additional
comments about the survey:
______________________________________________________________________________
______________________________________________________________________________
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