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For each family, the discussion about donation comes at a time of intense pain and loss.  At Nevada Donor Network, it is important to our staff that grieving families are treated with the utmost compassion and respect.  In our efforts to continually improve the quality of services provided to donor families, we would like to learn about your experience with our organization, as well as the reasons that led to your decision.  Your thoughts, along with the completion of this survey will help us learn how we can better help families at such a difficult time. 

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* 1. Your Name:

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* 2. Your Loved One’s Name:

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* 3. Your Loved One's birth date:

Date

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* 4. What is your relationship to the donor? I am his/her:

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* 5. Please rate the following:

  Strongly Agree Agree Disagree Strongly Disagree N/A
Overall, my experience with donation has been positive.
Organ/tissue donation has had a positive impact on my grief process.

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* 6. What inspired you to donate or support your loved one’s decision to donate? (Select all that apply)

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* 7. Please rate your experience with the Nevada Donor Network (NDN) staff member who discussed organ or tissue donation with you.

  Strongly Agree Agree Disagree Strongly Disagree N/A
The NDN staff was caring and compassionate.
The NDN staff provided my family with sufficient information to make an informed decision about donation.
The NDN staff kept me up to date on what was happening.
If I had questions, I knew how to get in contact with NDN staff.
The NDN staff discussed what types of support and resources I could receive through the Aftercare Program.

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* 8. If applicable, please rate the following experiences with the hospital care team (e.g., nursing staff, physicians, administration, etc.)

  Strongly Agree Agree Disagree Strongly Disagree N/A
The hospital care team kept me up to date about my family member’s condition.
The hospital care team shared my family member’s grave prognosis in a way I could understand.
The hospital care team provided me with the support I needed during my family member’s hospitalization.
During the donation process, the hospital care team was supportive of donation.

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* 9. If applicable, did the hospital care team discuss organ donation with you prior to Nevada Donor Network speaking with you?

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* 10. Based on your experience, would you be supportive of donation in the future?

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* 11. Are there any members of the NDN staff that stand out in your mind for any reason?

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* 12. Are there any members of another organization (hospital, hospice, sheriff’s office, coroner’s office, funeral home, etc.) that stand out in your mind for any reason?

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* 13. At the time of making arrangements with your funeral home, were you offered a donor hero condolence box?

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* 14. Nevada Donor Network is offering the opportunity for donor families to meet and interact with one another.  Would you be interested in this resource?

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* 15. Please share any suggestions to help us improve the way we support and communicate with families.

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* 16. Do you have any questions or would like someone from NDN to contact you regarding your experience?

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* 17. If you have any questions or would like someone from NDN to contact you regarding your experience, please provide the following contact information:

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* 18. If applicable, please provide the Case ID found at the top of the Anatomical Gift Form (optional):

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