Form 1 OMB DoNation Scorecard

OMB #0915-0373 EXP: 12/31/22

Public Burden Statement: The purpose of the scorecard and the collection of information is to incentivize and recognize workplaces and Organ Procurement Organization (OPO) participation in the ‘DoNation’ Campaign and to collect data regarding campaign participation. 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 0915-0373 and it is valid until 12/31/2025. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average .25 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 14N136B, Rockville, Maryland, 20857 or [email protected].

P lan Activities. Register Donors.
Join the national workplace campaign to save lives!

2023 ‘DoNation’ CAMPAIGN SCORECARD
October 1, 2022-September 30, 2023

Reach out to your local organ procurement organization to plan workplace campaign activities throughout the campaign year that promote organ, eye, and tissue donor registration. Use the activity scorecard below to track all activities and new donor registrations. Points earned for each activity and each new donor registration recorded will determine your level of recognition. Return your completed scorecard to your designated organ procurement organization (OPO) or directly to [email protected] to be recognized.

Workplace City/State/Zip

Workplace Contact Name Email

Reporting Donation Organization

Donation Organization

Contact Name Email

^{POINTS TOTAL} 0 DONOR REGISTRATIONS TOTAL ₀

SECTION 1: ‘DoNation’ Donor Registration Earn points for setting your donor registration goal, for reaching your goal, and for each new donor registration.
First, connect with your local donation organization partner—organ procurement organization (OPO), Donate Life America (DLA) affiliate, eye, or tissue bank—and set a realistic goal for the number of new donor registrations you want to achieve during the campaign.	Points Per Activity	List Donor Registration Goal Number	TOTAL Donor Registrations Recorded	Total Points
a) Set your goal for number of new donor registrations. (Earn 25 pts for one-time goal setting.)	25			0
b) Reach your goal. (Earn 50 pts for reaching or exceeding your goal for total number of new donor registrations recorded.)	50			0
c) Earn one point for each new donor registration recorded. (Example: 328 new donor registrations recorded = 328 to be put in “TOTAL Donor Registrations Recorded” column at right. The number entered in that column—328— will automatically go into “Total Points” column.)	1 pt. per each new donor reg.			0

SECTION 2: Workplace Communications, Outreach, and Events
Points Per Activity	Number Completed	Activity	Total Points
50		Host a campaign kick-off event.	0
50		Hold donor registry enrollment events.	0
25		Send email from CEO or other leaders to all staff, announcing the campaign and registration goal, encouraging participation and registration, providing campaign updates, and including link to state donor registry.	0
100		Conduct Give 5, Save Lives workplace challenge tactic. See materials and tips here.	0
15		Add ‘DoNation’ web badge with link to registry to all internal email signatures. See materials here.	0
15		Add ‘DoNation’ web badge with link to registry on company intranet. See materials here.	0
50		Add ‘DoNation’ web badge with link to registry on company web page. See materials here.	0
15		Display campaign posters and table tents with donation information and registry links in high-traffic public and employee areas, including on bulletin boards, in elevators, cafeteria, lobby, and restrooms.	0
15		Workplace Publish donation and transplantation articles, with registry link details, in internal newsletters and communications.	0
30		Send a letter to customers, vendors, and other companies encouraging them to join the campaign.	0
75		Coordinate an interdepartmental challenge to see which can get the most donor registrations.	0
75		Challenge another workplace to compete to see which can earn the most points for activities.	0
75		Partner with other workplaces and/or community organizations to run a collaborative campaign.	0
75		Contact local media and share the story of your involvement in the campaign.	0
5		Share ‘DoNation’ social media graphics on your social media platforms.	0
15		Participate in National Donate Life Blue & Green Day.	0
25		Include donation education, registry links/opportunities, and information about the campaign and ways to get involved in new employee orientations.	0
75		Provide donation information and registration opportunities at community health fairs/screening events. Partner with your local Health Department, mobile screening units, blood centers, and other community health organizations. [Want to learn more? Find out about these types of activities here. Reach out to your local OPO for ideas and support for implementing within your workplace.]	0
40		Hold a donor memorial service, a candle-lighting ceremony, Tree of Life, or other donation celebration. [Want to learn more? Find out about these types of activities here. Reach out to your local OPO for ideas and support for implementing within your workplace!]	0
25		Hold a Donate Life Flag Raising ceremony. [Want to learn more? Find out about these types of activities here. Reach out to your local OPO for ideas and support for implementing within your workplace!]	0
25		Hold a program with living donors, transplant recipients, donor family members, and/or transplant professionals to talk about the campaign and the importance of donation registration. [Want to learn more? Find out about these types of activities here. Reach out to your local OPO for ideas and support for implementing within your workplace!]	0
25		Hold a donor honor walk. [Want to learn more? Find out about these types of activities here. Reach out to your local OPO for ideas and support for implementing within your workplace.]	0
20		Present at company department or hospital department/physician meetings on campaign plans and registration goals. Suggest ways that staff can get involved. Consider inviting a representative from your area donation organization to speak.	0
50		Participate as a workplace team in a community walk/run promoting organ donation awareness.	0
50		Host a donation education program or segment with your local television station.	0
50 per		Conduct your own activity (up to 4 different activities). Enter a description of these activities.	0

Workplace

POINTS TOTAL ^{0 Total New Registrations 0}

Return your completed form to your designated OPO directly to [email protected].
If you have questions, please contact your OPO or email [email protected].