| S1. |
What is your zip code? (Open ended and code all five
digits of zip code)
99998 (DK)
99999 (Refused)
|
| S2. |
ETHNICITY: Are you, yourself, of Hispanic or Latino
origin or descent, such as Mexican, Puerto Rican, Cuban,
or other Spanish background?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| S3. |
RACE: What is your race? The U.S. census categories
are American Indian or Alaska Native, Asian, Black or
African-American, Native Hawaiian or other Pacific Islander,
or White. You may provide more than one answer, if appropriate.
(If necessary, read 06–07, 09–11,
then 01) (Allow three responses)
01 Some other race (list)
02 (DK)
03 (Refused)
04 HOLD
05 HOLD
06 White
07 African-American/Black
08 (Hispanic)
09 American Indian or Alaska Native
10 Asian
11 Native Hawaiian or other Pacific
Islander
|
| 1. |
In the past year, have you heard, read, or seen any
information at all about organ and tissue donation or
transplantation? (INTERVIEWER NOTE: If necessary, read:)
By ORGAN AND TISSUE DONATION, I mean the donation of organs,
such as hearts or kidneys from a person who has died,
or the donation of organs, such as kidneys or parts of
a liver or lung, from a person who is alive, and the donation
of tissues, such as skin, bone, or corneas from a person
who has died. Transplantation is the surgical transfer
of an organ or tissue from one person to another.
1 Yes — (Continue)
2 No(Skip
to #3)
3 (DK) (Skip
to #3)
4 (Refused) (Skip
to #3)
|
| 2. |
(If code 1 in #1, ask:) In the past
year, which of the following has been an important source
of information for you about organ and tissue donation
and transplantation? How about (read and rotate
A–R, then S)?
1 Yes
2 No
3 (DK)
4 (Refused)
5 (Not applicable)
A. A discussion with a family member
B. A discussion with a friend
C. Information provided by a medical
professional
D. Information provided by a member
of the clergy or your religious organization
E. Information provided by an attorney
F. Personal experience or involvement
with organ and tissue donation
G. A billboard or a poster in a
clinic or public place
H. General news media coverage
I. Your work or school
J. The Department of Motor Vehicles
K. A public service advertisement
on TV
L. A public service advertisement
on the radio
M. A movie and/or TV show
N. A community activity, such as
a health fair
O. The Internet or a Web site
P. The U.S. Department of Health
and Human Services
Q. An organ and tissue donation
organization
R. Local news (TV, radio, newspaper)
S. OR, Some other source (If
"Yes", ask:) What other source? (Open
ended)
01 Other
(list)
02 (DK)
03 (Refused)
04 No/No
other so
05 HOLD
|
| 3. |
Which sources of information would be most likely to
influence how you think or act about organ and tissue
donation and transplantation? (Open ended and code) (Allow
three responses)
01 Other (list)
02 (DK)
03 (Refused)
04 HOLD
05 HOLD
06 Family member
07 Friend
08 Medical professional
09 Clergy or religious organization
10 Attorney
11 Personal experience or involvement
with organ and tissue donation
12 Billboard or poster
13 General news media coverage
14 Work or school
15 Department of Motor Vehicles
16 Public service advertisement
on TV
17 Public service advertisement
on the radio
18 Movie or TV show
19 Community activity
20 Internet or a Web site
21 U.S. Department of Health and
Human Services
22 Organ and tissue donation organization
23 Local news (TV, radio, newspaper)
|
| 4. |
In general, do you strongly support, support, oppose,
or strongly oppose the donation of organs for transplants?
4 Strongly support
3 Support
2 Oppose
1 Strongly oppose
5 (DK)
6 (Refused)
|
| 5. |
How likely are you to have your organs donated after
your death? Would you say very likely, somewhat likely,
not very likely, or not at all likely?
4 Very likely
3 Somewhat likely
2 Not very likely
1 Not at all likely
5 (DK)
6 (Refused)
(If code 1
or 2 in #5, Continue;
If code 3 or
4 in #5, Skip to #6c;
Otherwise,
Skip to #9)
|
| 6a. |
Is there a particular reason you are not likely to have
your organs donated upon your death? (If "Yes",
ask:) What might that reason be? (Open ended and code)
01 Other (list)
02 (DK)
03 (Refused)
04 HOLD
05 HOLD
06 Against religion
07 Can't donate for medical reasons
08 Don't want body cut up or disfigured
09 Donation costs may be passed
to my family
10 Afraid they will take organs
before death
11 Don't trust the medical system,
feel they will not receive the best medical treatment
if they are a donor
12 Feel they are too old to donate
|
| 6b. |
Have you discussed with a member of your family your
wish NOT to donate your organs after your death?
1 Yes
2 No
3 (DK)
4 (Refused)
5 (Not applicable/No family members)
(If code 1
in #6b, Skip to #9;
If code 5 in
#6b, Skip to #12;
Otherwise,
Skip to #7)
|
| 6c. |
(If code 3 or 4 in #5, ask:) Have you
discussed your wish to be an organ donor with a member
of your family?
1 Yes
2 No
3 (DK)
4 (Refused)
5 (Not applicable/No family members)
(If code 1
in #6c, Skip to #9;
If code 5 in
#6c, Skip to #12;
Otherwise,
Continue)
|
| 7. |
(If code 2, 3, or 4 in #6b or #6c, ask:)
How willing are you to discuss your wishes about organ
and tissue donation with your family? Would you say very
willing, somewhat willing, not very willing, or not at
all willing?
4 Very willing (Skip
to #9)
3 Somewhat willing (Skip
to #9)
2 Not very willing (Continue)
1 Not at all willing (Continue)
5 (DK) (Skip
to #9)
6 (Refused) (Skip
to #9)
|
| 8. |
(If code 1 or 2 in #7, ask:) Is there
a particular reason why you are unwilling to discuss donation
with your family? (If "Yes", ask:)
What is the reason? (Open ended and code)
01 Other (list)
02 (DK/Haven't given it much thought)
03 (Refused)
04 No/No reason in particular
05 HOLD
06 Not applicable
07 Don't discuss death/makes them
nervous
08 Family would not understand
09 Family believes people should
be buried whole
10 They are too young
11 Not in good health
12 Personal/none of their business
13 It is their decision
14 Afraid that talking about their
death, will increase the chance that they will die
|
| 9. |
Has any member of your family told you about his or
her wish to donate or not to donate his or her organs
or tissues after death?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| 10. |
If you didn't know your family member's wishes, how
likely would you be to donate his or her organs and tissues
upon his or her death, if it were up to you? Would you
be very likely, somewhat likely, not very likely, or not
at all likely?
4 Very likely
3 Somewhat likely
2 Not very likely
1 Not at all likely
5 (DK)
6 (Refused)
7 (Not applicable)
|
| 11. |
If a family member HAD REQUESTED that his or her organs
and tissues be donated upon death, how likely would you
be to donate his or her organs and tissues if it were
up to you? Would you be very likely, somewhat likely,
not very likely, or not at all likely?
4 Very likely
3 Somewhat likely
2 Not very likely
1 Not at all likely
5 (DK)
6 (Refused)
7 (Not applicable)
|
| 12. |
Now I am going to read you a number of statements. For
each one, please tell me if you strongly agree, somewhat
agree, somewhat disagree, or strongly disagree. (Read
and rotate A–F)
4 Strongly agree
3 Somewhat agree
2 Somewhat disagree
1 Strongly disagree
5 (DK)
6 (Refused)
7 (Not applicable)
A. It is important for a person's
body to have all of its parts when it is buried
B. It is important for people to
tell their families whether or not they would want their
organs to be donated upon death
C. Most members of your family
support the idea of organ and tissue donation
D. Most people who receive transplants
gain additional years of healthy life
E. Organ donation allows something
positive to come out of a person's death
F. A deceased person's next of
kin should be able to override the deceased person's wish
to donate his or her organs
|
| 13. |
Have you granted permission for organ and tissue donation
(read and rotate A–C)?
1 Yes
2 No
3 (DK)
4 (Refused)
5 (Does not apply)
A. On your driver's license
B. On a signed donor card
C. By joining an organ donor registry
(If code 1
in #13–A, Continue;
Otherwise, Skip
to Note before #14b)
|
| 14a. |
Do you believe that marking organ donor on your license
"registers" you to be an organ donor?
1 Yes
2 No
3 (DK)
4 (Refused)
(If code 1
to ANY in #13 A–C, Skip to #15;
Otherwise, Continue)
|
| 14b. |
Would you be willing to grant permission for organ and
tissue donation on your driver's license, on a donor card,
or by joining an organ donor registry?
1 Yes
2 No
3 (DK)
4 (Refused)
(If code 2,
3, or 4 in #14b, Continue;
Otherwise, Skip
to #15)
|
| 14c. |
Why aren't you willing to grant permission for organ
and tissue donation? (Open ended) (RECORD VERBATIM
RESPONSE)
01 Other (list)
02 (DK)
03 (Refused)
04 No reason in particular
05 HOLD |
| 15. |
Some organs such as kidneys or parts of lungs or livers
can be donated while you are alive. How likely are you
to donate an organ while you are living to (read and rotate
A–C)? Would you say very likely, somewhat likely,
not very likely, or not at all likely?
4 Very likely
3 Somewhat likely
2 Not very likely
1 Not at all likely
5 (DK)
6 (Refused)
7 (Have donated)
A. A close friend
B. A family member
C. Someone you don't know
|
| 15a. |
Have you ever donated blood?
1 Yes — (Continue)
2 No (Skip to #16)
3 (DK) (Skip to #16)
4 (Refused) (Skip to #16)
|
| 15b. |
(If code 1 in #15a, ask:) How many
times in the past year have you donated blood? (Open ended
and code)
0 Zero or none
1 Once
2 Twice
3 Three times
4 Four times
5 Five times
6 Six times
7 Seven or more times
8 (DK)
9 (Refused)
|
| 16. |
Now I am going to read you several statements. For each
one, please tell me whether you strongly agree, somewhat
agree, somewhat disagree, or strongly disagree. (Read
and rotate A–M)
4 Strongly agree
3 Somewhat agree
2 Somewhat disagree
1 Strongly disagree
5 (DK)
6 (Refused)
7 (Not applicable)
A. All people who need an organ
transplant receive a transplant
B. Discrimination prevents minority
patients from receiving the organ transplants they need
C. You are worried that a loved
one's body would be disfigured if his or her organs were
donated
D. It is possible for a brain-dead
person to recover from his or her injuries
E. People who choose to donate
a family member's organs end up paying extra medical bills
F. Organ and tissue donation helps
families cope with their grief
G. Every year, thousands of people
die due to a lack of donated organs for transplantation
H. Organ and tissue donation can
often transmit diseases, such as HIV, hepatitis, or West
Nile virus
I. A person's wish to donate his
or her organs should be honored under all circumstances
J. There should be a registry of
people who wish to be organ donors that can be accessed
at the time of a persons death to make sure his or her
wishes are known
K. If you indicate you intend to
be a donor, doctors will be less likely to try to save
your life
L. Transplants often go to undeserving
people
M. You wouldn't want to donate
an organ yourself
|
| 17. |
Some countries presume that people wish to donate their
organs at death. This is called presumed consent. Their
organs may be used for transplanting unless they have
signed a document indicating that they don't wish to donate
their organs. Would you strongly support, support, oppose,
or strongly oppose using this presumed consent approach
in the United States?
4 Strongly support (Skip
to #17b)
3 Support (Skip to #17b)
2 Oppose (Continue)
1 Strongly oppose (Continue)
5 (DK) (Skip to #17b)
6 (Refused) (Skip to #17b)
|
| 17a. |
(If code 1 or 2 in #17, ask) Is there
a particular reason why you oppose presumed consent? (Open
ended and code)
01 Other (list)
02 (DK/Haven't given it much thought)
03 (Refused)
04 No/No reason in particular
05 HOLD
06 Feel presumed consent is unethical
07 Privacy issues
08 Violation of your rights
09 Distrust in the government
10 Religious preferences or beliefs
|
| 17b. |
Do you think a system of presumed consent would increase
or decrease the number of available organs for transplants?
3 Increase
2 (Stay the same/neither)
1 Decrease
4 (DK)
5 (Refused)
|
| 17c. |
If a system of presumed consent were adopted in the
United States, would you sign up as a non-donor?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| 18. |
It has been suggested that more organs would be donated
if families who donate the organs of a deceased loved
one received some type of payment, such as assistance
in paying funeral expenses, a cash award to the donor's
estate, or a cash award to a charity of the family's choice.
Would payments like these make you more likely or less
likely to donate (read and rotate A–B)
organs, or would it have no effect?
3 More likely to donate
2 Would have no effect
1 Less likely to donate
4 (DK)
5 (Refused)
6 (Not applicable)
A. Your own
B. A family members
(If code 3
in #18–A or #18–B, Continue;
Otherwise, Skip
to Note before #20)
|
| 19. |
Is there a particular reason a payment would make you
more likely to donate your organs or a family member's
organs? (If Yes, ask:) What reason? (Open
ended)
01 Other (list)
02 (DK)
03 (Refused)
04 No/No reason in particular
05 HOLD
(If code 1
in #18-A or #18-B, Continue;
Otherwise, Skip
to #21)
|
| 20. |
Is there a particular reason a payment would make you
less likely to donate your organs or a family member's
organs? (If Yes, ask:) What reason? (Open
ended)
01 Other (list)
02 (DK)
03 (Refused)
04 No/No reason in particular
05 HOLD
|
| 21. |
The medical and surgical expenses of individuals who
donate an organ while living are currently fully paid
by another source. Some people believe that these living
donors should also receive other compensation. Now I am
going to read you a few statements. For each one, please
tell me whether you strongly agree, somewhat agree, somewhat
disagree, or strongly disagree. (Read and rotate
A–B)
4 Strongly agree
3 Somewhat agree
2 Somewhat disagree
1 Strongly disagree
5 (DK)
6 (Refused)
7 (Not applicable)
A. Living donors should be compensated
for any expenses related to their donation, such as travel,
childcare, or lost wages.
B. Living donors should not be
denied health insurance or life insurance, nor should
they be required to pay greater premiums because they
donated an organ.
|
| 22. |
Now I am going to read you several statements. For each
one, please tell me whether you strongly agree, somewhat
agree, somewhat disagree, or strongly disagree. (Read
and rotate A–G)?
4 Strongly agree
3 Somewhat agree
2 Somewhat disagree
1 Strongly disagree
5 (DK)
6 (Refused)
7 (Not applicable)
A. Given equal need, a poor person
has as good a chance as a rich person of getting an organ
transplant
B. Doctors will do everything they
can to save a person's life before organ donation is even
considered
C. Organ transplantation is an
experimental medical procedure
D. Organ and tissue donation is
against your religion
E. People your age are too old
to donate organs
F. It is impossible to have a regular
funeral service following organ and tissue donation
G. People your age are too old
to receive transplants
|
| 23. |
Have you ever been an organ or tissue donor?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| 24. |
Have you ever received a donated organ or tissue?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| 25. |
Has any member of your family ever been an organ or
tissue donor, either while living or after death?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| 26. |
Has any member of you family ever received a donated
organ or tissue?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| DEMOGRAPHICS |
| D1. |
SEX: (Do not ask; code only)
1 Male
2 Female
|
| D2. |
AGE: What is your age? (Open ended and code
actual age)
00 (Refused)
99 99+
|
| D3. |
EDUCATION: What is the highest level of education you
have completed? (Open ended and code)
1 Less than high school graduate
(0-11)
2 High school graduate (12)
3 Some college
4 Trade/Technical/Vocational training
5 College graduate
6 Post-graduate work/degree
7 (DK)
8 (Refused)
|
| D4. |
NOT USED
|
| D5. |
NUMBER OF PHONE LINES: How many different residential
telephone lines do you have in this household? Don't count
extensions of the same number, dedicated business, fax,
or modem lines, or cellular phones that are not your only
residential number. (Open ended and code actual
number)
01-
97 97+
98 (DK)
99 (Refused)
|
| D6. |
How many adults age 18 or older live in your household?
(Open ended and code actual number)
01-
97 97+
98 (DK)
99 (Refused)
|
| D7. |
Do you work in the healthcare profession?
1 Yes
2 No
3 (DK)
4 (Refused)
|
| D9. |
INCOME: We want to classify people into
broad income groups for statistical purposes only. Is
your total annual household income, before taxes, over
or under $30,000?
(If Under, ask:) Is
it over or under $20,000?
(If Under, ask:) Is
it over or under $12,000?
(If Over, ask:) Is
it over or under $50,000?
(If Over, ask:) Is
it over or under $75,000?
(If Over, ask:) Is
it over or under $100,000?
1 Under $12,000
2 $12,000 to $19,999
3 $20,000 to $29,999
4 $30,000 to $49,999
5 $50,000 to $74,999
6 $75,000 to $99,999
7 $100,000 or more
8 (DK)
9 (Refused) |
