2 OMB Hospital Campaign Challenge Scorecard CLEAN

Healthcare Workplaces for Organ Donation

2019 Campaign Scorecard

Plan Activities, Register Donors, and Let Life Bloom

Plan your 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 by the Health Resources and Services Administration (HRSA) and the national partners. Return completed scorecard to your donation organization partner (organ procurement organization (OPO), Donate Life America (DLA) affiliate, or eye or tissue bank).

Healthcare Organization Name: City/State/ZIP:

Healthcare Contact Name: Email:

Reporting Donation Organization: Organization

Contact Name: Email:

^{POINTS TOTAL} 0

OMB #0915-0373 EXP: 03/31/2020

DONOR REGISTRATIONS TOTAL ₀

SECTION 1: Donor Registrations Earn points for setting your donor registration goal, for reaching your goal, and for each new donor registration.
First, consult with your donation organization partner—OPO, DLA affiliate, eye or tissue bank—to set a realistic goal for the number of new donor registrations you want to achieve during the campaign.	Points Per Activity	List Donor Registration Goal Number	TOTAL Donor Registrations Recorded	Total Points
a) Set your goal for number of new donor registrations. (Earn 50 pts for one-time goal setting.) SET GOAL	50			0
b) Reach your goal. (Earn 100 pts for reaching or exceeding your goal for total number of new donor MET GOAL registrations recorded.)	100			0
c) Earn one point for each new donor registration recorded. (Example: 328 new donor registrations recorded = 328 to be put in “TOTAL Donor Registrations Recorded” column at right. The number entered in that column—328— will automatically go into “Total Points” column.)	1 pt per each new donor reg.			0

SECTION 2: Internal Communications and Events
Points Per Activity	Number Completed	Activity	Total Points
75		Organize or join a challenge competition among participating healthcare organizations.	0
65		Hold direct donor registry enrollment events (tabling events) in high-traffic areas.	0
65		Hold a campaign kick-off event or other large-scale event that is reported by news media; consider featuring a donor family and/or transplant recipient.	0
65		Implement Give 5 – Save Lives direct donor registration tactic. See materials and tips here.	0
65		Place a campaign web banner and link to the state registry on internal email signatures and web sites for the duration of the campaign.	0
40		Enlist auxiliary/volunteers in donation registry/awareness events.	0
40		Hold a donor memorial service, candle-lighting ceremony, Tree of Life, or other donation celebration.	0
25		Hold a donation flag-raising ceremony for employees. Invite community members.	0
25		Send email from the CEO/other leaders to all staff, announcing the campaign, encouraging participation and registration, providing campaign updates, and including link to state donor registry.	0
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.	0

20		Present at departmental/physician meetings on plans and registration goal of the campaign. Suggest ways that staff can get nvolved. Consider inviting a representative from your area donation organization to speak.	0
20		Utilize your organization’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.	0
20		Add campaign goal marker/barometer to your website and/or post in public area.	0
15		Display campaign posters and table tents with donation information and registry links in high-traffic public and employee areas, including on bulletin boards, in elevators, cafeteria, lobby, and restrooms.	0
15		Publish donation and transplantation articles, with registry link details, in internal newsletters.	0
15		Participate in National Blue and Green Day (Friday, April 12).	0
15		Enter a description of one or more of your own activities not listed above.	0

SECTION 3: Community Engagement and Events
Points Per Activity	Number Completed	Activity	Total Points
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.	0
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.	0
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.	0
75		Organize a challenge competition among local medical schools or universities/colleges.	0
75		Host a donation education program or segment with local media.	0
65		Participate as a team in a community walk/run promoting organ donation awareness.	0

40		Post donation-related info/story and link to state registry on billboards.	0
35		Place an ad/PSA about organ, eye, and tissue donation, with link to state registry, in the local media (news, radio, TV).	0
25		Send letter/email from the CEO to other hospitals, health organizations, physician practices, or community groups, encouraging them to join the campaign, with links to resources and state registry.	0
25		Use social media sites (Facebook, Twitter, LinkedIn, Instagram) to highlight community donation events, provide link to state registry, and encourage registration.	0
25		Create a pro-donation theme and use in community parade, event, and/or health fair.	0
25		Submit a letter to the editor of area publication, urging donation registration and providing state registry link.	0
25		Add state registry link to your website.	0
25		Publish donation/transplant articles, with registry link details, in community newsletter or local newspaper or publication.	0
15		Place donation-related posters with state registry details in local businesses.	0
15		Enter a description of one or more of your own activities not listed above.	0

POINTS TOTAL ^{0 Total New Registrations 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 .5 hours 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