6 20170303 Attachment 6__Survey _Screener Questionnaire -

OMB Number 0915-0212 - Expiration date 05/31/2018

Draft 50+ Donor Survey

10 minute online survey

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

Screening Questions:

S1: What is your age? ____

1. [50-80 continue]

2. [Else, SCREEN OUT]

S2. What is your gender?

1. Male

2. Female

S3. 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)

S4. Are you currently or have you ever been registered as an organ donor, either by registering at the Department of Motor Vehicles, on a donor card, or an organ donor registry?

1. Yes (SCREEN OUT)

2. No

S5. How is your health overall? Would you say:

1. Excellent

2. Good

3. Fair

4. Poor (SCREEN OUT)

Start of Survey:

Thanks for agreeing to participate in the survey. You will see a series of ads about organ donation. Please view each item and then answer the questions about that item.

[SHOW ADS IN RANDOM ORDER. REPEAT QUESTIONS FOR EACH AD.]

1. This ad got my attention.

[Sliding scale from not a lot to a great deal]

2. This ad makes it clear that organ donation helps people.

[Sliding scale from not a lot to a great deal]

3. I like this ad.

[Sliding scale from not a lot to a great deal]

4. I believe this ad.

[Sliding scale from not a lot to a great deal]

5. This ad makes me want to learn more about donation.

[Sliding scale from not a lot to a great deal]

6. This ad makes me want to register to be an organ donor

[Sliding scale from no chance to absolutely]

[END OF REPEATING QUESTIONS]

[SHOW ALL ADS TOGETHER]

7. The ad I like best is:

1. Ad 1

2. Ad 2

3. Ad 3

4. Ad 4

5. Ad 5

6. Ad 6

8. The reason I like this ad is: _________________

9. Here are some possible things people might want to know about organ donation. Please rate how much you want to learn about each of the following topics, using a scale from 1 (not that much) to 10 (a great deal): [SHOW IN RANDOM ORDER]

1. How to register to be an organ donor

2. What it means to register as a donor

3. Who gets organs/how organ recipients are selected

4. If there is an age limit for who can donate organs

5. How many people need organs

6. What organs can be donated

7. How organ donation happens

8. How donation helps people

9. Why some people need organs

10. Here are some possible reasons people might decide to be an organ donor. Please rate how much each makes you want to consider donation, using a scale from 1 (not that much) to 10 (a great deal): [SHOW IN RANDOM ORDER]

1. To help someone else in need

2. Because it’s quick and easy to do

3. Because it shows that I care about others

4. Because I can make a difference

5. Because it’s my decision to make

6. To save up to eight lives

7. If I make the decision, then my family will know my wishes

8. Because there are people like me who need an organ

9. To be a hero

10. Because I know the story of someone helped by donation

11. Because I know the story of someone who saved a life

12. Because I want to be the one who decides

13. To control my own future

11. Where would you want to learn more about organ donation? [select all that apply]

1. Website

2. Social media

3. Poster or printed materials

4. Radio

5. TV

6. From your doctor

7. From friends

8. From family

9. Other: _______________

10. None

12. When you got your driver’s license, were you asked if you wanted to be a donor?

1. Yes

2. No

13. Did you feel like you had enough information at that time to make a good decision?

1. Yes

2. No (If no, please explain why not?): ____________________________

14. Where have you ever gotten information about organ donation? [select all that apply]

1. Website

2. Social media

3. Poster or printed materials

4. Radio

5. TV

6. From your doctor

7. From friends

8. From family

9. Other: _______________

10. None

15. How important do you think it is for people to know about organ donation? [Scale from 1 not very important to 10 very important]

16. How easy is it for you to talk about organ donation with other adults? [Scale from 1 not very easy to 10 very easy]

17. How important is it for you to talk about organ donation with other adults? [Scale from 1 not very important to 10 very important]

18. Do you think you will register in the future to be an organ donor?

1. Yes

2. No

19. Please explain your answer above: ____________________

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 to better explain organ donation issues.

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 0915-0212. Public reporting burden for this collection of information is estimated to average .5 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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