Form 2 Survey on VCA Donation

Draft VCA Survey

Online Survey with HRSA Customers

10 minute online survey

Data collected from panel provider:

• Age (21-64)

• Race

• Ethnicity

• Income

• Education

Thank you for agreeing to take part in this study. It should take about 10 minutes.

Screening Questions:

S1. To begin, thinking about organ donation, do you strongly support, support, oppose, or strongly oppose organ donation?

1. Strongly support

2. Support

3. Oppose (SCREEN OUT)

4. Strongly Oppose (SCREEN OUT)

S2. Are you currently a registered organ donor, either by registering on your driver’s license, a donor card, or an organ donor registry?

1. Yes (DONOR)

2. No (CONTINUE)

S3. Have you ever been a registered organ donor, either by registering on your driver’s license, a donor card, or an organ donor registry?

1. Yes (SCREEN OUT)

2. No (PASSIVE POSITIVE)

S4. What is your gender?

1. Male

2. Female

Start of Survey:

Randomly assign respondents to condition, n=100 per cell of design

Each cell should have n=20 male donor; n=20 female donor; n=30 male passive positive; n=30 female passive positive

Control 1: Fact-based information on organ donation

Control 2: Recipient story on organ donation

Experimental 1: Fact based VCA hands and face together

Experimental 2: Recipient story VCA face (Vet)

Experimental 3: Recipient story VCA hands (non-Vet)

Experimental 4: Recipient story VCA hands (Vet)

Experimental 5: Donor/recipient story VCA hands (Vet)

Please read the following paragraph and then select continue when you have finished.

[SHOW STIMULUS]

Survey Questions:

{Insert text about how to use sliding scale questions to show agreement}

The following questions are about organ donation (for example a heart or a kidney) after a person has died.

1. How I feel about organ donation

[Sliding scale from Not a good thing to An extraordinarily good thing]

2. How much does organ donation help people

[Sliding scale from Not a lot to A great deal]

3. I will register to be an organ donor [PASSIVE POSITIVES]

I will stay registered as an organ donor [DONORS]

[Sliding scale from No chance to Absolutely]

4. People like me are organ donors

[Sliding scale from Disagree to Agree]

5. I will visit a Web site or take other steps to learn more about organ donation in the next month

[Sliding scale from Disagree to Agree]

6. I will have a conversation with someone else about organ donation in the next month

[Sliding scale from Disagree to Agree]

7. If I was going to have a conversation with someone about organ donation, I would tell them: ________________ [open-end]

{screen break}

The following questions are about Vascularized Composite Allograph (VCA) donation. In this type of donation, structures such as bone, nerves, blood vessels, and muscles may be donated after a person has died. This may include hands or faces.

8. How I feel about VCA donation

[Sliding scale from Not a good thing to An extraordinarily good thing]

9. How much does VCA donation help people

[Sliding scale from Not a lot to A great deal]

10. If a loved one died, I would consider donating his or her hands

[Sliding scale from No chance to Absolutely]

11. If a loved one died, I would consider donating his or her face

[Sliding scale from No chance to Absolutely]

12. I will visit a Web site or take other steps to learn more about VCA/hand/face donation in the next month

[Sliding scale from Disagree to Agree]

13. I will have a conversation with someone else about VCA/hand/face donation in the next month

[Sliding scale from Disagree to Agree]

14. If I was going to have a conversation with someone about VCA/hand/face donation, I would tell them: ________________ [open-end]

{screen break}

15. Prior to participating in this study, had you ever heard the term Vascularized Composite Allograph (VCA) donation?

    1. Yes

    2. No

    3. Maybe/not sure

16. Prior to participating in this study, had you ever heard of someone receiving a donation of a face or a hand?

    1. Yes

    2. No

    3. Maybe/not sure

17. In general, what do you think about hand/face donation? [open-end]

18. Where would you want to learn more information about hand/face donation? [select all that apply]

    1. Web site

    2. Newspaper or magazine article

    3. Story on the radio

    4. Story on television

    5. Advertisements

    6. From your doctor

    7. From friends or family

    8. Other

    9. None

19. Americans can indicate their desire to donate their organs after they die by registering online or via an indicator on a driver’s license. If someone has registered as a donor, it indicates they are willing to donate which of the following: [select all that apply]

    1. Organs such as hearts, lungs, or kidneys

    2. Eyes

    3. Tissue such as veins or heart valves

    4. Structures such as bone, nerves, blood vessels, and muscles (including hands and face)

    5. None of the above

20. How does learning about hand/face donation affect your desire to register as an organ donor?

    1. Makes me much more interested

    2. Makes me more interested

    3. No effect

    4. Makes me less interested

    5. Makes me much less interested

21. If you knew registering to be an organ donor does not indicate a willingness to donate hands and face, would you be

a.     Much more likely to register as an organ donor

b.     More likely to register as an organ donor

c.     Unaffected by that information

d.     Less likely to register as an organ donor

e.     Much less likely to register as an organ donor

End:

Thank you for participating in this study. This study is being sponsored by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). HRSA is the Federal Agency charged with overseeing organ donation and transplantation in the United States. HRSA is conducting this study to understand how better to explain organ donation issues to the American people, including explaining about new advances in transplantation such as VCA/hand/face donation.

More information on organ donation is available at organdonor.gov.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is XXX. Public reporting burden for this collection of information is estimated to average .17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857.

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