Form 1 FINALCleanChallengeScorecard

Plan Activities, Register Donors,

and Let Life Bloom

2017 HOSPITAL CAMPAIGN SCORECARD

Pan your hospital’s campaign activities to promote donor registration and then track activities and new donor registrations here. Points earned for each activity and for each new donor registration recorded will determine your level of recognition in the WPFL Hospital Campaign. Return the completed scorecard to your donation organization partner (OPO, DLA Affiliate, eye, or tissue bank).

1,000 Points =

750 Points = 350 Points =

200 Points =

Hospital City/State/Zip

Hospital Contact:

Name Email

Reporting Donation Organization

Donation Organization Contact:

Name Email

P OINTS TOTAL ⁰ DONOR REGISTRATIONS TOTAL ⁰

OMB #0915-0373 EXP: X/XX/XXXX

	Check the circles below		Points per Activity	Goal Setting
			50	Set a goal for the number of new donor registrations you want to record through your campaign. Report your goal and progress to your donation organization partner (OPO, DLA, eye, or tissue bank).
			100	Reach or exceed your goal.
	# of new donor registrations you recorded		Points per Activity	New Donor Registrations
			1 point. for each new donor registration	Put the number of new donor registrations you recorded in the far left-hand box and an equal number of points will be added to your total points. (Example: if you recorded 384 donor registrations, put 384 in the left-hand box and you will earn 384 points toward recognition.)
	# of each Activity Completed	Points per Activity		Hospital Communications and Events	New Registrations
		65		Hold direct donor registry enrollment events (tabling events) in high-traffic hospital areas.
		60		Hold a Hospital Campaign kick-off event or other large-scale event that is reported by news media; consider featuring a donor family and/or transplant recipient.
		50		Implement Give 5 – Save Lives direct donor registration tactic. See materials and tips here.
		50		Participate in a challenge competition among area hospitals.
		50		Place a campaign web banner and link to the state registry on internal email signatures and web sites for the duration of the campaign.
		40		Enlist hospital auxiliary/volunteers in donation registry/awareness events.
		40		Hold a donor memorial service, candle-lighting ceremony, Tree of Life, or other donation celebration.
		25		Hold a donation flag-raising ceremony for employees. Invite community members.
		25		Send email from hospital CEO/other leaders to all staff, announcing the campaign, encouraging participation and registration, providing campaign updates, and including a link to state donor registry.
		25		Hold a program with living donors, transplant recipients, donor family members, and/or transplant professionals to talk about the campaign and the importance of donation registration.
		25		Include donation education, registry links/opportunities, and information about the campaign and ways to get involved in new employee orientations.
		20		Present at departmental/physician meetings on plans and the registration goal for the campaign. Suggest ways that staff can get involved. Consider inviting a representative from your area donation organization to speak.
		20		Utilize hospital's internal media to run campaign PSAs, post e-versions of campaign materials, and/or feature short videos on donation and transplantation. Access videos on organdonor.gov or on HRSAtube.
		20		Add campaign goal challenge marker/barometer to your website and/or post in public area.
		15		Display campaign posters and table tents with donation information and registry links in hospital’s high-traffic public and employee areas including on bulletin boards, in elevators, cafeteria, lobby, and restrooms.
		15		Publish donation and transplantation articles, with registry link details, in internal hospital newsletters.
		15		Participate in National Blue and Green Day.
		15		Enter a description of one or more of your own activities not listed above.

OMB #0915-0373 EXP: X/XX/XXXX ^{continues next page …}

# of each Activity Completed	Points per Activity	Community Engagement and Events	New Registrations
	75	Provide donation information and registration opportunities at community health fairs/screening events. Partner with your local Health Department, mobile screening units, blood centers, and other community health organizations.
	75	Partner with your municipality, area colleges/universities, chamber of commerce, local businesses, and fraternal organizations (e.g., veterans, Rotary Club, Kiwanis) to engage new partners in the campaign and help host awareness and donor registry enrollment events.
	75	Partner with local police, firefighters, EMS, and other first responders to engage new partners in the campaign and help host awareness and donor registry enrollment events.
	50	Hold direct donor registry enrollment events (tabling events) in high-traffic areas in the community.
	50	Organize a challenge competition among local medical schools or universities/colleges.
	50	Host a donation education program or segment with your local television station.
	50	Participate as a hospital team in a community walk/run promoting organ donation awareness.
	40	Post donation-related info/story and link to state registry on billboards.
	35	Place an ad/PSA about organ, eye, and tissue donation, with link to state registry, in the local media (news, radio, TV).
	25	Send letter/email from hospital CEO to other hospitals, health organizations, physician practices, or community groups encouraging them to join the campaign, with links to resources and state registry.
	25	Use social media sites (Facebook, Twitter, LinkedIn, Instagram) to highlight community donation events, provide link to state registry, and encourage registration.
	25	Create a pro-donation theme and use in community parade, event, and/or health fair.
	25	Submit a letter to the editor to an area publication, urging donation registration and providing state registry link.
	25	Add a state registry link to your website.
	25	Publish donation/transplant articles, with registry link details, in a hospital community newsletter or other local print/online publication or forum.
	15	Place donation-related posters with state registry details in local businesses.
	15	Enter a description of one or more of your own activities not listed above:

POINTS TOTAL ^{0 REGISTRATIONS TOTAL 0}

Return your completed form to your donation organization. If you have questions, contact your donation organization or email wpfl@akoyaonline.com.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0373. Public reporting burden for this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857. Expires: X/XX/XXXX.