2 FORM Survey Questions CLEAN

OMB No. 0915-0212 Exp. Date 07/03/2021

Online Survey

HRSA Minority Organ Donation

Thank you for your interest in registering to become an organ donor! Please consider answering a few short questions to help us learn more about your decision. Your feedback is voluntary and confidential.

1. To begin, please tell us briefly why you are interested in registering as an organ donor: _________________________________.

2. Is there anything you’ve seen or read recently that influenced your decision?

   1. Yes

   2. No

3. [IF YES] What did you see or hear that made you more interested in becoming a donor? ________________________

4. How satisfied are you with the information on the organdonor.gov website?

   1. Very satisfied

   2. Somewhat satisfied

   3. Neither satisfied nor dissatisfied

   4. Somewhat dissatisfied

   5. Very dissatisfied

5. What could we do to improve your experiences with the website? __________________

Finally, for demographic reasons, please tell us a little about yourself.

6. Are you:

   1. Male

   2. Female

7. Which category best describes your age?

   1. 20 or younger

   2. 21–35 years old

   3. 36–49 years old

   4. 50–65 years old

   5. 66 or older

8. Which racial or ethnic groups do you identify with? Please select all that apply.

   1. White

   2. Black or African American

   3. Asian

   4. Native Hawaiian or Other Pacific Islander

   5. Hispanic or Latino/Latina

   6. American Indian or Alaskan Native

Thank you for taking the time to answer these questions. We really appreciate your help.

The purpose of this collection is to obtain feedback from customers and potential customers related to the HRSA Division of Transplantation’s (DoT) outreach materials on organ donation and transplantation for minority audiences. The results of this collection will enable HRSA DoT to appropriately address the unique information needs of minorities in its communication materials and outreach efforts. 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 information collection is 0915-0212 and it is valid until 07/03/2021. This information collection is voluntary. All information obtained will be used by HRSA DoT, and will not be shared with the public. Public reporting burden for this collection of information is estimated to average ten (10) 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 14N136B, Rockville, Maryland, 20857 or [email protected].