OMB Number: 0916-XXXX
Expiration Date: XX/XX/20XX
Potential Living Donor Follow-up Form
Brief survey instrument used to maintain contact with all participants at approximately 1 year after completed registration
1. Thank you for the actions you took to be evaluated as a living donor. Regardless of whether or not you donated, we want to learn more about the effects that considering donation or becoming a living donor had on your life. We invite you to be part of a registry to examine the effects over time of being evaluated or donating. Would you be willing to help us by answering a series of short questions going forward?
yes
no
other: ______________________________
2. Confirm address and phone numbers and preferred method of contact: ______________________________________________
3. Would you say your health in general is:
excellent
very good
good
fair
poor
declined to respond or don’t know
4. Compared with before evaluation for donation, would you say your health is:
much better
somewhat better
not different
somewhat worse
much worse
declined to respond or don’t know
5. Do you have an impairment or health problem that limits your ability to walk or run?
yes
no
declined to respond or don’t know
6. Are you limited in the kind or amount of work you can do because of a physical, mental, or emotional problem?
yes
no
declined to respond or don’t know
7. In general, how you would rate your mental health, including your mood or ability to think?
excellent
very good
good
fair
poor
declined to respond or don’t know
8. In general, how would you rate your satisfaction with your social activities and relationships?
excellent
very good
good
fair
poor
declined to respond or don’t know
9. Please rate how much of a financial burden volunteering to donate has been to you and your family.
(check one box)
No financial burden |
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Extreme financial burden |
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0 |
1 |
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5 |
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7 |
8 |
9 |
10 |
10. If you could do it over again, would you?
definitely yes
probably yes
not sure
probably not
definitely not
declined to respond or don’t know
Public Burden Statement: 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–XXXX. Public reporting burden for this collection of information is estimated to average 30 minutes 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 14N39, Rockville, MD 20857.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Laura Klein |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |