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Organ Donation -Form Fill
Q1
Have you ever heard of organ donation, or not?
Yes
No
Don’t Know
Refused
Q2
Have you or has anyone in your immediate family ever donated an organ?
Yes
No
Don’t Know
Refused
Q3
Have you or has anyone in your immediate family ever been forced or tricked into having an organ removed for someone else?
Yes
No
Don’t Know
Refused
Q4
Gender?
Male
Female
Not Applicable
Don’t Know
Don’t Know
Q5
How old [were you/was your immediate family member at the time [your/their] organ was removed?
Yes
No
Don’t Know
Refused
Q6
Which organ did [you/your immediate family] donate?
Cornea
Liver
Lung
kidney
Other
Not applicable
Don’t Know
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