Form 1 Revised Survey

National Survey of Organ Donation Attitudes and Practices

FINAL DRAFT – February 15, 2012

Project Registration #138293
HEALTH RESOURCES AND SERVICES ADMIN.	_X__ TRANSLATIONS
City Center: Washington DC
National Organ and Tissue Donor	X SURVEY DESIGN: Tara McGhee
Wells/Bechtolt
Jane Wood, Specwriter
August, 2011	n=3,250

I.D.#:

______ (1- 6)

**AREA CODE AND TELEPHONE NUMBER:

______ ______ (649 - 658)

**INTERVIEW TIME:

______ ______ (716 - 721)

(NOTE: All interviews are recorded. The recording begins when the respondent answers the phone. This statement is read after the "Continue" response is entered after the Introduction and before the first question) This call will be recorded for quality assurance.

1 (Continue)

2 (Refused) - (Thank and Terminate) (984)

Sa. STATE: (Code from fone file)

______ ______

___________________________________________ (54) (55)

Sb. Sample:

1 African-American Recontact sample (Panel) (n=500)

2 Hispanic Recontact sample (G1K) (n=500)

3 Asian Recontact sample (G1K) (n=500)

4 National sample (RDD) (n=1250)

5 American Indian Recontact sample (G1K) (n=500)

Sc. Sample Type

1 Landline

2 Cell

Sd. Age from G1K (Code from sample file)

Se. Gender from G1K (Code from sample file)

1. Male

2. Female

PANEL ENTITY

QID:38395 ENTITY ID:

QID:82080 **PANEL HOUSEHOLD SAMPLE:

_____ Single Household
_____ Multi-household

	If Sb = 4 read, otherwise skip to note before Intro #2 Intro #1 Hello, my name is _______, and I am calling from The Gallup Organization. I am calling on behalf of the U.S. Department of Health and Human Services. We're conducting a national survey about organ donation. Am I speaking to someone 18 or older? (If "Yes", continue; if "No", ask to speak to someone who is 18 or older)
	1 Respondent available - (Continue)
	4 No one 18 or older in household – (Thank and Terminate)
	7 Respondent not available/Not a good time - (Set time to call back)
	8 (Soft Refusal)
	9 (Hard Refusal) - (Thank and Terminate)	_____(1001)

If Sc = 1 read S1, otherwise skip to note before S1A:

S1. First, I would like to identify the adult in your household, 18 or older, who had the most recent birthday. Who would that be?

1 Respondent - (Continue)

2 Someone else in household - (Ask to speak to that person, then reset to Introduction)

4 No adults 18 or over in household – (Thank, Terminate, and Tally)

7 Respondent not available – (Record First name and set time to call back)

9 (Refusal) – (Thank and Terminate) _____(1020)

If Sb = 2, 3, or 5 read:

Intro #2

Hello, my name is _______, and I am calling from The Gallup Organization. I am calling on behalf of the U.S. Department of Health and Human Services. We're conducting a national survey about organ donation. We previously conducted a survey with a (INSERT RESPONSE FROM SD) year old (INSERT RESPONSE FROM SE) in this household) who gave permission for us to call again. May I speak with that person?

1. Respondent

2. Respondent not available (Set time to call back)

3. No such person/person moved (Thank and Terminate)

4. (Refusal) (Thank and Terminate)

If Sb=1, continue. Else skip to note before S1A

INTRO #3

QID:32747 Hello, this is _____, calling for the Gallup Panel. I am calling on behalf of the U.S. Department of Health and Human Services. We're conducting a national survey about organ donation. May I speak with (name from fone file)?

1 Yes, respondent available

3 No longer at this number

4 Respondent wants removed from Panel

5 Household wants removed from Panel

7 Respondent not available/Not a good time

8 (Soft Refusal)

9 (Hard Refusal)

QID:128132 Skip: (If code 3 in INTRO, Continue;
If code 4 or 5 in INTRO, Skip to P2;
If code 1 in INTRO, Skip to P3;
If code 7 in INTRO, Set time to call back;
If code 8 or 9 in INTRO, Thank, Terminate, and Tally)

P1

QID:32752 Since (name from fone file) is a member of the Gallup Panel, may I have his/her new telephone number, starting with the area code?

(Interviewer: Back up to dialer and enter new number, then code as appropriate in Introduction)

1 Yes

2 No

8 (DK)

9 (Refused)

QID:128135 Skip: (If code 1 in P1, Back up to dialer and enter new number, and code as appropriate in Introduction;
Otherwise, Thank, Terminate, and Tally)

P2

QID:48184 Why [(If code 4 in Introduction, read:) do you/(If code 5 in Introduction, read:) does your household] no longer want to be on the Panel?

(Programmer: Open ended and code)

0001 Other (list) [TO BE CODED]

0002 (DK)

0003 (Refused)

0004 HOLD

0005 HOLD

0006 Don't have the time/too time-consuming/takes too much time to do the surveys

0007 Topics/content of surveys/don't like the topics (general)

0008 Only want to do "meaningful" surveys (general)

0009 Expected political polls/current events/ social issues topics only

0010 Not paid anything for surveys

0011 Too many surveys to do/too frequent

0012 Too many phone calls

0013 No longer a member of the (original Panel) household

0014 Moving/household move - no forwarding address/phone

0015 Illness/family hardship

0016 Didn't realize what this was

0017 Calling times/Don't like the times I'm called

# of Responses:3 List Other:Y

QID:128136 Skip: (All in P2, Thank, Terminate, Tally, and Keep Case I.D.)

If (Sc = 1) ask:

S1a. Have I reached you on a cell phone or landline phone?

1. Landline

2. Cell

3. (Don’t Know)

4. (Refused)

(READ:) This is an important study of people's opinions about organ donation. Your assistance in this study is voluntary, but your opinions are needed to provide an accurate understanding of the public's views. If there is any question you do not wish to answer, just tell me. Your answers are confidential and will be combined with those of others. You as an individual will never be identified. The questions will require about fifteen minutes of your time.

S2. ETHNICITY: Are you, yourself, of Hispanic or Latino origin or descent, such as Mexican, Puerto Rican, Cuban, or other Spanish background?

1 Yes

2 No

3 (DK)

4 (Refused) _____(1007)

(If code 1 in S2, Continue;

Otherwise, Skip to S3)

S2a. Are you Mexican, Cuban, Puerto Rican, or some other nationality? (If "Some other nationality", ask:) What nationality would that be?

01 Other (list)

02 (DK)

03 (Refused)

04 HOLD

05 HOLD

06 Mexican

07 Cuban

08 Puerto Rican

______ ______

___________________________________________ (1409) (1410)

S3

QID:145637       Next, I am going to read you a list of racial groups. As I read each one, please tell me whether you are -- or are not -- a member of that racial group. You may consider yourself to be a member of more than one racial group. How about __________?

                        (Interviewer: read S3A-S3D)

1          Yes

2          No

3          (DK)

4          (Refused)

S3A	QID:145638	White	D50A(2478)
S3B	QID:145639	Black or African-American	D50B(2479)
S3C	QID:145640	Asian or Pacific Islander	D50C(2480) D50C1(2570)
S3D	QID:146901	American Indian or Alaskan Native	D50C_1(2570)

If code 1 in S3C, Continue. Else skip to note before #1.

S3.

“Would that be Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or Some Other Asian”? (Allow three responses)

01 Some other race (list)

02 (DK)

03 (Refused)

04 HOLD

05 HOLD

12 Asian Indian

13 Chinese

14 Filipino

15 Japanese

16 Korean

17 Vietnamese

18 Other Asian (including Hmong, Laotian, Thai, Pakistani, Cambodian) (List)

1st ______ ______

________________________________ Resp: (1008) (1009)

2nd ______ ______

________________________________ Resp: (1070) (1071)

3rd ______ ______

________________________________ Resp: (1072) (1073)

If code 1 in Sb, and S3b<>1, Thank and Terminate.

If code 2 in Sb, and S2<>1, Thank and Terminate

If code 3 in Sb, and S3c<>1, Thank and Terminate

If code 5 in Sb, and S3d<>1, Thank and Terminate

1. In the past year, have you heard, read, or seen any information at all about organ donation or transplantation? (INTERVIEWER NOTE: If necessary, read:) By ORGAN AND TISSUE DONATION, I mean the donation of organs, such as hearts or kidneys from a person who has died, or the donation of organs, such as kidneys or parts of a liver or lung, from a person who is alive. Transplantation is the surgical transfer of an organ from one person to another.

1 Yes - (Continue)

2 No (Skip to #3)

3 (DK) (Skip to #3)

4 (Refused) (Skip to #3) _____(1301)

2. (If code 1 in #1, ask:) In the past year, please tell me whether each of the following has been an important source of information for you about organ donation and transplantation. How about (read and rotate A-U, then V)?

1 Yes

2 No

3 (DK)

4 (Refused)

5 (Not applicable)

A. A discussion with a family member _____(1302)

B. A discussion with a friend _____(1303)

C. Information provided by a medical professional, clinic, or doctor’s office _____(1304)

D. Information provided by a member of the clergy or your religious organization _____(1305)

E. Information provided by an attorney _____(1306)

F. Personal experience or involvement with organ, eye, and tissue donation _____(1307)

G. A billboard or a poster in a public place _____(1308)

H. News coverage (TV, radio, newspaper,internet) _____(1309)

I. Your work or school _____(1310)

J. A Motor Vehicles Office _____(1311)

K. An advertisement on TV _____(1312)

L. An advertisement on the radio _____(1313)

M. A movie and/or a TV show _____(1314)

N. A community activity, such as a health fair _____(1315)

_____(1317)

2. (Continued:)

Q. An organ and tissue donation organization _____(1318)

_____(1319)

S. A senior center or other older adult setting

T. Social media such as Facebook, YouTube, or Twitter

U. Health related or other web sites

V. OR, Some other source (If "Yes", ask:) What other source? (Open ended)

01 Other (list)

02 (DK)

03 (Refused)

04 No/No other source

05 HOLD

______ ______

___________________________________________ (1320) (1321)

3. Which sources of information would be most likely to influence how you think or act about organ donation and transplantation? (Open ended and code) (Allow three responses)

01 Other (list)

02 (DK)

03 (Refused)

04 HOLD

05 HOLD

06 Family member

07 Friend

08 Doctor’s office

09 Clergy or religious organization

10 Attorney

11 Personal experience or involvement with organ and tissue donation

12 Billboard or poster

13 HOLD

14 Work or school

15 A Motor Vehicles Office

16 An advertisement on TV

17 An advertisement on the radio

18 Movie or TV show

19 An actor or an athlete

20 Community activity

21 News coverage (TV, radio, newspaper, or Internet)

22 HOLD

23 Organ donation organization

24 Senior center or other older adult setting

25 HOLD

26 Social media (such as Facebook, YouTube, or Twitter)

27 Health related web sites

1st ______ ______

________________________________ Resp: (1322) (1323)

2nd ______ ______

________________________________ Resp: (1324) (1325)

3rd ______ ______

________________________________ Resp: (1326) (1327)

4. In general, do you strongly support, support, oppose, or strongly oppose the donation of organs for transplants?

4 Strongly support

3 Support

2 Oppose

1 Strongly oppose

5 (DK)

6 (Refused) _____(1328)

13. Have you granted permission for organ donation (read and rotate A-C)?

1 Yes

2 No

3 (DK)

4 (Refused)

5 (Does not apply)

A. On your driver’s license _____(1346)

B. On a signed donor card _____(1347)

C. By joining your state donor registry_____(1348)

If code 1 in #13A, B or C, skip to #6bc

(If code 2, 3, 4, or, 5 to ALL in #13 A-C Continue)

)

5. Regardless of whether you have formally granted permission, would you want your organs to be donated after your death? Would you say definitely yes, probably yes, probably no, or definitely no?

4 Definitely yes

3 Probably yes

2 Probably no

1 Definitely no

5 (DK)

6 (Refused) _____(1329)

(If code 1 or 2 in #5, Skip to #6a;

If code 3 or 4 in #5,Continue;

If code 5 or 6, Skip to #9)

14b. Would you be willing to grant permission for organ donation by joining your state’s organ donor registry?

1 Yes

2 No

3 (DK)

4 (Refused) _____(1350)

(If code 2, 3, or 4 in #14b, Continue;

Otherwise, Skip to #14d)

14c. Why aren’t you willing to sign up to be a donor in your state donor registry? (Open ended) (RECORD VERBATIM RESPONSE)

01 Other (list)

02 (DK)

03 (Refused)

04 No reason in particular

05 HOLD

______ ______

__________________

14d. (If code 1 in #14b ask:) Why haven’t you registered to be a donor with your state donor registry? (Open ended)

01 Other (list)

02 (DK)

03 (Refused)

04 No reason in particular

05 HOLD

(All in #14d skip to #6bc)

6a. (If code 1 or 2 in #5 ask:) Is there a particular reason you do not want to have your organs donated upon your death? (If "Yes", ask:) What might that reason be? (Open ended and code)

01 Other (list)

02 (DK)

03 (Refused)

04 HOLD

05 HOLD

06 Against religion

07 Can't donate for medical reasons

08 Don’t want body cut up or disfigured

09 Donation costs may be passed to my family

10 Afraid they will take organs before death

11 Don’t trust the medical system, feel they will not receive the best medical treatment if they are a donor

12 Feel they are too old to donate

______ ______

___________________________________________ (1330) (1331)

6b. Have you discussed with a member of your family your wish NOT to donate your organs after your death?

1 Yes

2 No

3 (DK)

4 (Refused)

5 (Not applicable/No family members) _____(1332)

6bb. Is there one thing that could change your mind to want to be a donor? (If Yes) What would that be?

01 (Other)

02 (Don’t Know)

03 (Refused)

04 No/Nothing Would Change My Mind

(If code 1 in #6b, Skip to #9;

If code 5 in #6b, Skip to Note before #12;

If code 3 or 4 in #5 Continue,

Otherwise, Skip to #7)

6bc. If you had to identify the single biggest reason why you want to be a donor, what would that be? (Open ended and code)

01 (Other)

02 (Don’t Know)

03 (Refused)

04 No/no reason

6c. (If code 3 or 4 in #5, ask:) Have you discussed your wish to be an organ donor with a member of your family?

1 Yes

2 No

3 (DK)

4 (Refused)

5 (Not applicable/No family members) _____(1333)

(If code 1 in #6c, Skip to #9;

If code 5 in #6c, Skip to Note before #12;

Otherwise, Continue)

7. (If code 2, 3, or 4 in #6b or #6c, ask:) How willing are you to discuss your wishes about organ donation with your family? Would you say very willing, somewhat willing, not very willing, or not at all willing?

4 Very willing (Skip to #9)

3 Somewhat willing (Skip to #9)

2 Not very willing (Continue)

1 Not at all willing (Continue)

5 (DK) (Skip to #9)

6 (Refused) (Skip to #9) _____(1334)

8. (If code 1 or 2 in #7, ask:) Is there a particular reason why you are unwilling to discuss donation with your family? (If "Yes", ask:) What is the reason? (Open ended and code)

01 Other (list)

02 (DK/Haven’t given it much thought)

03 (Refused)

04 No/No reason in particular

05 HOLD

06 Not applicable

07 Don’t discuss death/makes them nervous

08 Family would not understand

09 Family believes people should be buried whole

10 They are too young

11 I am not in good health

12 Personal/none of their business

13 It is their decision

14 Afraid that talking about their death, will increase the chance that they will die

15 Someone in my family is not in good health and may need my organs

______ ______

___________________________________________ (1335) (1336)

9. Has any member of your family told you about his or her wish to donate or not to donate his or her organs after death?

1 Yes

2 No

3 (DK)

4 (Refused) _____(1337)

10. If you didn’t know your family member’s wishes, how likely would you be to donate his or her organs upon his or her death, if it were up to you? Would you be very likely, somewhat likely, not very likely, or not at all likely?

4 Very likely

3 Somewhat likely

2 Not very likely

1 Not at all likely

5 (DK)

6 (Refused)

7 (Not applicable) _____(1338)

11. If a family member HAD REQUESTED that his or her organs be donated upon death, how likely would you be to donate his or her organs if it were up to you? Would you be very likely, somewhat likely, not very likely, or not at all likely?

4 Very likely

3 Somewhat likely

2 Not very likely

1 Not at all likely

5 (DK)

6 (Refused)

7 (Not applicable) _____(1339)

12. Now I am going to read you a number of statements. For each one, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree. (Read and rotate A-H, as appropriate)

4 Strongly agree

3 Somewhat agree

2 Somewhat disagree

1 Strongly disagree

5 (DK)

6 (Refused)

7 (Not applicable)

A. It is important for a person's body to have all of its parts when it is buried _____(1340)

B. It is important for people to tell their families whether or not they would want their organs to be donated upon death _____(1341)

C. Most members of your family support the idea of organ donation _____(1342)

D. Most people who receive transplants gain additional years of healthy life _____(1343)

E. Organ donation allows something positive to come out of a person's death _____(1344)

F. A deceased person’s next of kin should be able to override the deceased person’s wish to donate his or her organs _____(1345)

G. Organs should be distributed so that the expected life of the organ is similar to the expected life of the recipient. For example, older people should generally get older organs and younger people should get younger organs. _____(1431)

H. All people who need an organ transplant should be able to receive a transplant

14e. Some organs such as kidneys or parts of lungs or livers can be donated while you are alive. Have you ever donated an organ or part of an organ?

1. Yes

2. No

3. (Don’t know)

4. (Refused)

If 14e = 1 then skip to 16., Otherwise Continue

15. Assuming you are medically able, how likely would you be to agree to donate an organ while you are living to (read and rotate A-C)? Would you say very likely, somewhat likely, not very likely, or not at all likely?

4 Very likely

3 Somewhat likely

2 Not very likely

1 Not at all likely

5 (DK)

6 (Refused)

7 (Have donated)

A. A close friend _____(1353)

B. A family member _____(1354)

C. An acquaintence

D. Someone you don’t know _____(1355)

15e. 15e. Recent medical breakthroughs have resulted in successful face and hand transplants for people who have suffered the loss of limbs or facial disfigurement from traumatic injuries, such as accidents and war.  How willing would you be (interviewer read 4-1) (Read and rotate A&B)

4 Very willing

3 Somewhat willing

2 Not very willing

1 Not at all willing

5 (DK)

6 (Refused)

1. To donate your hands

2. To donate your face

16. Now I am going to read you several statements. For each one, please tell me whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree. (Read and rotate B-Q)

4 Strongly agree

3 Somewhat agree

2 Somewhat disagree

1 Strongly disagree

5 (DK)

6 (Refused)

7 (Not applicable)

B. Discrimination prevents minority patients from receiving the organ transplants they need _____(1359)

C. You are worried that a loved one's body would be disfigured if his or her organs were donated _____(1360)

D. It is possible for a brain-dead person to recover from his or her injuries _____(1361)

E. People who choose to donate a family member's organs end up paying extra medical bills _____(1362)

F. Organ donation helps families cope with their grief _____(1363)

G. Every year, thousands of people die due to a lack of donated organs for transplantation _____(1364)

_____(1365)

I. A person’s wish to donate his or her organs should be honored under all circumstances, even over the objections of surviving family members. _____(1366)

16. (Continued:)

K. If you indicate you intend to be a donor, doctors will be less likely to try to save your life _____(1368)

L. Transplants often go to undeserving people _____(1369)

N. You would agree to receive an organ transplant if it would save your life

O. People over 50 can donate their organs.

P. People over 50 can receive a transplant.

Q. The U.S. transplant system uses a fair approach to distribute organs to patients.

If 2, 3, 4, or 5 in 13A., 13B, AND 13C., Ask 16a. Otherwise skip to #17

16a. Please choose the statement that comes closer to your view: (rotate 1 and 2)

1. If I were a donor, I would like my organs to go to the more medically urgent patients regardless of where they live in the U.S.

OR

2. If I were a donor, I would like my organs to go to patients in my local area even if they are not the more medically urgent patients waiting for an organ

3. (Don’t Know/Refused)

17. Some countries assume that people wish to donate their organs at death. This is called presumed consent. Their organs may be used for transplanting unless they have signed a document indicating that they don't wish to donate their organs. Would you strongly support, support, oppose, or strongly oppose using this presumed consent approach in the United States?

4 Strongly support (Skip to #17b)

3 Support (Skip to #17b)

2 Oppose (Continue)

1 Strongly oppose (Continue)

5 (DK) (Skip to #17b)

6 (Refused) (Skip to #17b) _____(1371)

17a. (If code 1 or 2 in #17, ask) Is there a particular reason why you oppose presumed consent? (Open ended and code)

01 Other (list)

02 (DK/Haven’t given it much thought)

03 (Refused)

04 No/No reason in particular

05 HOLD

06 Feel presumed consent is unethical

07 Privacy issues

08 Violation of your rights

09 Distrust in the government

10 Religious preferences or beliefs

1st ______ ______

________________________________ Resp: (1372) (1373)

2nd ______ ______

________________________________ Resp: (1374) (1375)

3rd ______ ______

________________________________ Resp: (1376) (1377)

17b. Do you think a system of presumed consent would increase or decrease the number of available organs for transplants?

3 Increase

2 (Stay the same/neither)

1 Decrease

4 (DK)

5 (Refused) _____(1378)

17c. If a system of presumed consent were adopted in the United States, would you opt out to ensure you are not a donor?

1 Yes

2 No

3 (DK)

4 (Refused) _____(1379)

18.

It has been suggested that more organs would be donated if families who donate the organs of a deceased loved one received assistance in paying funeral expenses, a cash award to the donor’s estate, or a cash award to a charity of the family’s choice. Would payments like these make you more likely or less likely to donate (read and rotate A-B) organs or would it have no effect.

3 More likely to donate

1. Would have no effect

1. Less likely to donate

4. (DK)

5. (Refused)

6. (Not applicable)

1. Your own

2. A family member’s at their time of death

_____(1381)

(If code 3 in #18-A, #18-BContinue;

Otherwise, Skip to Note before #20)

19. Is there a particular reason a payment would make you more likely to donate your organs or a family member’s organs? (If Yes, ask:) What reason? (Open ended)

01 Other (list)

02 (DK)

03 (Refused)

04 No/No reason in particular

05 HOLD

______ ______

___________________________________________ (1382) (1383)

(If code 1 in #18-A, #18-B, Continue;

Otherwise, Skip to #21)

20. Is there a particular reason a payment would make you less likely to donate your organs or a family member’s organs? (If Yes, ask:) What reason? (Open ended)

01 Other (list)

02 (DK)

03 (Refused)

04 No/No reason in particular

05 HOLD

______ ______

___________________________________________ (1384) (1385)

22. Now I am going to read you several statements. For each one, please tell me whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree. (Read and rotate A-G)?

4 Strongly agree

3 Somewhat agree

2 Somewhat disagree

1 Strongly disagree

5 (DK)

6 (Refused)

7 (Not applicable)

A. Given equal need, a poor person has as good a chance as a rich person of getting an organ transplant _____(1388)

B. Doctors do everything they can to save a person's life before organ donation is even considered _____(1389)

C. Organ transplantation is an experimental medical procedure _____(1390)

D. Organ and tissue donation is against your religion _____(1391)

E. People your age can donate organs _____(1392)

F. It is impossible to have a regular funeral service following organ and tissue donation _____(1393)

G. People your age can have organ transplants _____(1394)

H. Many people on the national waiting list for organs die because an organ doesn’t become available in time.

23. Have you, or has anyone close to you, ever been an organ, eye or tissue donor or ever received a transplant?

1 Yes

2 No

3 (DK)

4 (Refused) _____(1395)

DEMOGRAPHICS BEGIN HERE:

READ: Finally, I have a few questions for classification purposes only. (If Sb=1, 2, 3, or 5, Read: You may have been asked similar questions in the past.)

D1. SEX: (Do not ask; code only)

1 Male

2 Female _____(1404)

(DEMOGRAPHICS CONTINUED)

D2. AGE: What is your age? (Open ended and code actual age)

00 (Refused)

99 99+

______ ______

___________________________________________ (1405) (1406)

D3. EDUCATION: What is the highest level of education you have completed? (Open ended and code)

1 Less than high school graduate (0-11)

2 High school graduate (12)

3 Some college

4 Trade/Technical/Vocational training

5 College graduate

6 Post-graduate work/degree

7 (DK)

8 (Refused) _____(1407)

D4a. MARITAL STATUS: What is your current marital status? (Programmer: (Read 1-5, then 8)

1 Single/Never been married

2 Married

3 Separated

4 Divorced

5 Widowed

8 Domestic partnership/Living with partner (not legally married)

6 (DK)

7 (Refused)

(Question D4a deleted)

(Question D4b moved to S2a)

(Question D4c deleted)

D5. (If Sb = 4 and Sc=1 ask:) How many different residential phone NUMBERS do you have coming into your household, not including lines dedicated to a fax machine, modem, or used strictly for business purposes? Do not include cellular phones.

(Programmer: (Open ended and code actual number))

0 Zero

1 One

2 Two

3 Three

4 Four

5 Five or more

6 (DK)

7 (Refused)

(DEMOGRAPHICS CONTINUED)

D6. (If Sb = 4 and Sc = 1 ask:) How many adults age 18 or older live in your household? (Open ended and code actual number)

01-

97 97+

98 (DK)

99 (Refused)

______ ______

___________________________________________ (1421) (1422)

D6a. (If S1a = 1 or 3 or 4 ask:) Do you have a cell phone that you use to make and receive personal calls?

1. Yes

2. No

3. (Don’t Know)

4. (Refused)

D6b. (If S1a=2 or Sc = 2 ask:) Do you have a regular, landline telephone in your home that you use to make and receive personal calls?

1. Yes

2. No

3. (Don’t Know)

4. (Refused)

D6c. (If code 1 in D6a. or D6b. ask:) Of all the telephone calls your household receives (read 1-3)?

1 All or almost all calls are received on cell phones

2 Some are received on cell phones and some on regular phones, OR

3 Very few or none are received on cell phones

4 (DK)

5 (Refused)

D7. Do you work in the healthcare profession?

1 Yes

2 No

3 (DK)

4 (Refused) _____(1423)

(Question D8 deleted)

D8. What is your zip code? (Open ended and code all five digits of zip code)

99998 (DK)

99999 (Refused)

______ ______

____________________________________________ (1002 - 1006)

D9

QID:130971 What is your total MONTHLY household income, before taxes? Please include income from wages and salaries, remittances from family members living elsewhere, farming, and all other sources.

(Programmer: Open ended and code)

(Interviewer: [If response is greater than $10,000, read:) Is that a monthly or an annual amount? (If monthly, code as appropriate; if annual, probe for monthly amount)])

01 Under $60

02 $60 to $499

03 $500 to $999

04 $1,000 to $1,999

05 $2,000 to $2,999

06 $3,000 to $3,999

07 $4,000 to $4,999

08 $5,000 to $7,499

09 $7,500 to $9,999

10 $10,000 to $14,999

11 $15,000 to $19,999

12 $20,000 and over

98 (DK)

99 (Refused)

D45(2492-2493)

QID:141253 Skip: (If code 98 or 99 in D9, Continue;
Otherwise, Skip to Closing)

D10

QID:130974 Is your total MONTHLY household income before taxes $4,000 or more, or is it less than $4,000?

(Interviewer:
(If under, ask:) Is it over or under $3,000?
(If under, ask:) Is it over or under $2,000?
(If under, ask:) Is it over or under $1,000?
(If under, ask:) Is it over or under $500?
(If under, ask:) Is it over or under $60?)

(Interviewer:
(If over, ask:) Is it over or under $5,000?
(If over, ask:) Is it over or under $7,500?
(If over, ask:) Is it over or under $10,000?
(If over, ask:) Is it over or under $15,000?
(If over, ask:) Is it over or under $20,000?)

01 Under $60

02 $60 to $499

03 $500 to $999

04 $1,000 to $1,999

05 $2,000 to $2,999

06 $3,000 to $3,999

07 $4,000 to $4,999

08 $5,000 to $7,499

09 $7,500 to $9,999

10 $10,000 to $14,999

11 $15,000 to $19,999

12 $20,000 and over

98 (DK)

99 (Refused)

(READ:) That completes our survey; however, we are required by law to report to you the OMB Control Number for this public information request. That number is 0915-0290, which expires October 31, 2005.

Results of the survey will be available in about six months on a government Web site. Would you like the Web site address? (If yes:) The address is www.organdonor.gov, that is spelled O-R-G-A-N-D-O-N-O-R (one word) dot-G-O-V.

(VALIDATE PHONE NUMBER AND

THANK RESPONDENT BY SAYING:)

Again, this is _____, with The Gallup Organization of _____. I would like to thank you for your time. Our mission is to "help people be heard" and your opinions are important to Gallup in accomplishing this.

INTERVIEWER I.D. #: _____(571-

574)

jlw\2005\HRSA\HRSA National organ and tissue donation survey 0502

36

HRSA National Organ DONOR Survey