1) Are you an organ and tissue donor? Yes No If no, is this due to: Doubt/Fear Never Considered It Not Interested 2) Have you heard about Get Carded on your campus? Yes No If yes, how did you hear about us: Event Through Your Student Organization Word of Mouth 3) Are you interested in learning more about organ and tissue donation? Yes No If yes, what topic are you most interested in: Facts & Myths Statistics Designating Your Wishes to Donate Life 4) Would you be interested in joining the Get Carded program to spread the word about LIFE? Yes No If yes, please go to the Main Menu and click on Campuses to locate your university. You will be able to contact the committee via e-mail or phone. 5) Please review the following facts on donation: Donation saves lives. Today, more than 90,000 children and adults await lifesaving organ transplants. Hundreds of thousands more await the gift of tissue donation. All major religions support donation, considering it the greatest gift. There is no charge to the donor family for donation. If you are ill or unconscious and admitted to the hospital, the number one priority is to save your life. Donation is only considered after death. To be an organ and tissue donor, sign a donor card and carry it in your wallet. You may also have it listed on your Florida Driver License. Remember to share your wishes to donate life with your loved ones. 6) If you answered "NO" to the first question, are you more likely to be an organ donor now that you know the facts? Yes No 7) Do you plan on printing a Uniform Donor Card from our Web site to complete and place in your wallet? Yes No If yes, do you plan on telling your family about your decision? Yes No 8) Have you found our Web site helpful? Yes No 9) Biographical Information: (A) What year are you (i.e., freshman)? (B) What university do you attend? (C) Male Female (D) Ethnicity/Race (E) Age (F) What is your major? (G) E-mail Address (optional) (H) I know someone who has been touched by donation. Yes No 10) Comments: Would you like to notify friends about this form? Email Address 1: Email Address 2: Email Address 3: Email Address 4:
