Age:
14-16 17-18 19-21 22-25 26-30 31-40 41-50 51-60 61+

Gender:
Male Female

Location:
Postcode/Zipcode* Country of residence
*For UK postcodes please enter only the first part of the postcode (i.e. "SW7")

Section 1: Are you currently a registered donor of:
  Name of UK register Yes No
Blood National Blood Service
Organs/Tissues NHS Organ Donor Register (ODR)
Bone Marrow stem cells BBMR or Anthony Nolan Trust

Section 2: What was the initial source of information that made you decide to sign up?
  Blood Organs/Tissues Bone Marrow
Family
School
Further education e.g. University
Friend/acquaintance
Media
Work
Advertising by charities/organisations
Internet
GP surgery
Other (please state)

Section 3a: Has your decision not to be a donor for Blood been influenced by any of the following? (please tick all that apply):
  Definitely
applies 		Applies to a
great extent 		Applies
somewhat 		Does not
apply at all
Attitude of family and friends
Lack of information
Bad publicity
Not a high personal priority
I am frightened to do it
I am concerned that there may be health risks
for me
I cannot be a donor because of age
restrictions (too old/too young)
I have a medical condition so I don't think my
blood would be suitable to donate
My personal beliefs
Other (please state)

Section 3b: Has your decision not to be a donor for Organs/Tissue been influenced by any of the following? (please tick all that apply):
  Definitely
applies 		Applies to a
great extent 		Applies
Somewhat 		Does not
apply at all
Attitude of family and friends
Lack of information
Bad publicity
Not a high personal priority
I am frightened to do it
I am concerned that there may be health risks
for me
I cannot be a donor because of age
restrictions (too old/too young)
I have a medical condition so I don't think my
organs/tissues would be suitable to donate
My personal beliefs
Other (please state)

Section 3c: Has your decision not to be a donor for Bone Marrow been influenced by any of the following? (please tick all that apply):
  Definitely
applies 		Applies to a
great extent 		Applies
Somewhat 		Does not
apply at all
Attitude of family and friends
Lack of information
Bad publicity
Not a high personal priority
I am frightened to do it
I am concerned that there may be health risks
for me
I cannot be a donor because of age
restrictions (too old/too young)
I have a medical condition so I don't think my
Bone Marrow would be suitable to donate
My personal beliefs
Other (please state)


How clear was this questionnaire?
Very clear Fairly clear Neither clear nor unclear Very unclear


Thank you for taking the time to answer this survey. This data will be used to complete an annual report to the UK Health Minister and UK Shadow Heath Minister so that we can measure the effectiveness of an Education Programme in schools being launched in September 2007 which covers Blood, Organs/tissue and Bone Marrow donation.

If you would like a copy of the annual report or to subscribe to our e-newsletter please give your email address and a copy will be sent to you when it is published.


Email address*
I would like to subscribe to the e-newsletter
Please send me a copy of the Annual Report

*Your e-mail address will be kept as confidential and the Jeanette Crizzle Trust will not share this information with any third party.





 © Copyright of The Jeanette Crizzle Trust. 2006 All rights reserved Designed and developed by Duffin Slessor Dodd