I am an IUPUI undergraduate student currently doing a study on organ donation. My goal is to fin out what groups of people are most likely to donate organs and why they donate. Please take a few minutes to answer the following questions. Thank you for your participation.

1. What is your age group?

__18-24
__25-35
__36-50
__50 and above

2. What is your ethnicity?

__Caucasian
__Black America
__Hispanic
__Asian
__Indian American
__Other___________

3. What is your sex?

__Male
__Female

4. What is the highest level of education you have attended?

__High School Diploma
__Attended Some College
__Undergraduate Degree
__Graduate Degree

5. How many people have you known, either living or deceased, that have donated organs? ___________________

6. If you have known someone who has donated are you aware as to why they or their family chose to donate? Please explain.

______

7. Where have you seen or heard advertisements promoting donations? Please circle all that apply.

__ Television
__ Billboards
__ Radio
__ Magazines and Newspapers
__ BMV
__ Other_____________

8. What would be the major factors in your decision to donate. Please circle all that apply.

__ Family Member In Need of an Organ
__ Saw an Advertisement
__ Religion Promotes or Discourages It
__ Other_________

9. Are you adesignated donor on your driver’s license?

__ Yes
__ No
__ Not Sure

10. Is your family aware of your wishes concerning donation, and do you know what their wishes are ?

__________

11. If you were asked to donate the organs of a loved one, do you believe you would, and if so

why would you?

_______________