3 SRTR Form Potential Living Donor Follow-up Form_1 yr_10-

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

Brief Follow-Up Contact by SRTR

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							Extreme financial burden
▼										▼
0	1	2	3	4	5	6	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.