1 NSODAP CATI Script English R10 0290

OMB control number 0915-0290 Expiration XX/XX/2024

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Public Burden Statement: The overall purpose of this study is to conduct an independent multi-mode (web and
telephone) survey of public opinion regarding various issues related to organ donation. 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 0915-0290 and expires xx/
xx/2024. Public reporting burden for this collection of information is estimated to average 0.27 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
Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

PROJECT – HRS R658
INTRO1
Hello, my name is _______, and I am calling from American Directions Research Group. I am calling
on behalf of the U.S. Department of Health and Human Services. We're conducting a national survey
about organ donation. Am I speaking to someone 18 or older? (Skip: If "Yes", continue; if "No", ask to
speak
18 or
older)nue)
1. toRsomeone
espondentwho
avais
ilable
-(Conti
2. No one 18 or older in household – (Thank and Terminate)
3. Respondent not available/Not a good time -(Set time to call back)
4. (Soft Refusal)
5. (Hard Refusal) -(Thank and Terminate)
(Skip this question if cell/landline data present in sample file)
S1B Have I reached you on a cellphone or landline phone?
1. Landline
2. Cell
3. (DK)
4. (Refused)
(If S1B = Landline)
S1 First, I would like to identify the adult living in your household, 18 or older, who had the most
recent birthday. Who would that be?
1.
2.
3.
4.
5.

Respondent -(Skip to S1B)
Someone else in household -(Ask to speak to that person, then reset to Introduction)
No adults 18 or over in household – (Thank, Terminate, and Tally)
Respondent not available – (Record First name and set time to call back)
(Refusal) – (Thank and Terminate)

(If S1B = Cell)

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
S1C For your safety, are you currently driving?
1. Yes [SET CALLBACK IF DRIVING, ELSE CONTINUE]
2. No
3. (DK)
4. (Refused)
INTRO 2
This is an important study of people's opinions about organ donation. Your assistance in this study is
voluntary, but your opinions are needed to provide an accurate understanding of the public's views. If
there is any question you do not wish to answer, just tell me. Your answers are confidential and will be
combined with those of others. You, as an individual, will never be identified. The questions will
require about 20 minutes of your time.
Q1

In the past year, have you heard, read, or seen any information at all about organ donation
or transplantation?
1.
2.
3.
4.

Yes
No
Don’t Know
Refused

[IF NECESSARY READ] By ORGAN DONATION, I mean the donation of organs,
such as hearts or kidneys from a person who has died, or the donation of organs, such as
kidneys or parts of a liver or lung, from a person who is alive. Transplantation is the
surgical transfer of an organ from one person to another. Organ donation does not include
donation of bone marrow or tissue, such as skin or corneas.

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q2

(If Q1 = Yes) In the past year, how have you seen or heard about organ donation or
transplantation?
[RESPONSE CODES]
1.
2.
3.
4.

Yes
No
DK
Refused

How about [READ AND ROTATE]:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
Q2A

A discussion with a family member
A discussion with a friend
Information provided by a medical professional, clinic, or doctor's office
Information provided by a member of the clergy of your religious organization
Information provided by an attorney
Personal experience or involvement with organ, eye or tissue donation
A billboard or a poster in a public place
News coverage (TV, radio, newspaper, or internet)
Your work or school
A Motor Vehicles Office (MVA, DMV, or SOS)
An advertisement on TV
An advertisement on the radio
A movie and/or a TV show
A community activity, such as a health fair
An organ or tissue donation organization
A senior center or other older adult setting
Social media such as Facebook, Instagram, YouTube, or Twitter
Search engines, such as Google, Yahoo, or Bing
Other websites
Some other source

(If Q2T = Yes)
What is that other source? [open-ended response RECORD VERBATIM]

Q2B

(If Q2Q = Yes)
Which social media websites? [open-ended response RECORD VERBATIM]

Q2C

(If Q2R = Yes)
Which search engine websites? [open-ended response RECORD VERBATIM]

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q2D

(If Q2S = Yes)
Which other websites? [open-ended response RECORD VERBATIM]

Q2E

(If Q2Q or Q2R or Q2S = Yes)
When you are online, do you typically use a computer, a hand-held mobile device, such as a
smart phone or tablet, or do you use both?
1.
2.
3.
4.
5.

Computer
Mobile device
Both
DK
Refused

Q3

Which sources of information would be most likely to influence how you think or act about
organ donation and transplantation? [open-ended response RECORD VERBATIM]

Q4

In general, do you strongly support, support, oppose, or strongly oppose the donation of
organs for transplantation?
1.
2.
3.
4.
5.
6.

Q13

Strongly support
Support
Oppose
Strongly oppose
DK
Refused

Have you signed up to be an organ donor?
1.
2.
3.
4.

Yes
No
DK
Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q13A

(If Q13 = Yes) (rotate Q13A A-D) How did you sign up?
1.
2.
3.
4.

Yes
No
DK
Refused

A Your State’s Department of Motor Vehicles, Motor Vehicle Department, or Secretary of
State Office
B. At a donor registration drive or event
C. Through a mobile phone app
D. Through a website
E. Some other way
Q13B

(If Q13A=E ‘Some other way’)
What other way did you sign up to be an organ donor? [open-ended response RECORD
VERBATIM]

Q13C

(If Q13A = D (website))
Did you sign up using a hand-held mobile device such as a smart phone or tablet?
1.
2.
3.
4.

Q5

Yes
No
DK
Refused

(If Q13 NOT = Yes)
Would you want your organs to be donated after your death? Would you say definitely yes,
probably yes, probably no, or definitely no?
1.
2.
3.
4.
5.
6.

Definitely Yes
Probably Yes
Probably No
Definitely No
DK
Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q14B

(If Q5 = definitely yes or probably yes)
Would you be willing to sign up to be an organ donor?
1.
2.
3.
4.

Q14C

Yes [SKIP TO Q14D]
No [SKIP TO Q14C]
DK
Refused

(If Q14B = NO)
Is there a particular reason why you do not want to sign up to be an organ donor? [openended response RECORD VERBATIM]

Q14C1

(If Q14C = “don’t know” or “no reason”)
Would you say it is for one of these reasons?
1.
2.
3.
4.
A.
B.
C.
D.
E.

Q14D

Yes
No
DK
Refused

Haven’t thought about it
I would need more information
Because of medical reasons
I feel I am too old to donate
I don’t believe I will receive the best medical treatment if I’m a donor

(If Q14B =YES)
Is there a particular reason why you have not signed up to be an organ donor? [open-ended
response RECORD VERBATIM]

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q14E

(If Q5 = definitely yes or probably yes)
Would you be willing to sign up to be an organ donor through a hand-held mobile device
such as a smart phone or tablet?
1.
2.
3.
4.

Q6A

Yes
No
DK
Refused

(If Q5 NOT = definitely yes or probably yes)
Is there a particular reason why you do not want your organs donated upon your death? If
Yes, what might that reason be?
1. [open-ended response RECORD VERBATIM]
2. DK
3. Some Other Reason

Q6A1

(If Q6A = “don’t know” or “no reason”)
Would you say it is for one of these reasons?
1.
2.
3.
4.
A.
B.
C.
D.
E.
F.
G.

Yes
No
DK
Refused

It’s against my religion
For medical reasons
I don’t want my body cut up or disfigured
Donation costs might be passed to my family
They might take my organs before death
I don’t believe I will receive the best medical treatment if I’m a donor
I feel I am too old to donate

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q6B

(If Q5 NOT = definitely yes or probably yes)
Have you discussed with a member of your family your wish not to donate your organs after
your death?
1.
2.
3.
4.
5.

Q6BB

Yes
No
DK
Refused
N/A or No Family Members

(If Q5 NOT = definitely yes or probably yes)
Is there one thing that could change your mind to want to be a donor?
1.
2.
3.
4.

Q6BC

Yes [SPECIFY AND RECORD VERBATIM]
No
DK
Refused

(If Q13 = Yes)
If you had to identify the biggest reason or reasons why you want to be an organ donor,
what would those be? [Open-ended response RECORD VERBATIM]

Q6BD

(If Q6BC= “don’t know” or “no reason”)
Would you say it is for one of these reasons?
1.
2.
3.
4.

Yes
No
DK
Refused

A. To save a life
B. I won’t need them any longer
C. It’s the right thing to do

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q6C

(If Q13 = Yes)
Have you discussed your wish to be an organ donor with a member of your family?
1.
2.
3.
4.
5.

Q7

Yes
No
DK
Refused
N/A or No Family Members

(If Q6C NOT Yes)
How willing are you to discuss your wishes about organ donation with your family? Would
you say very willing, somewhat willing, not very willing, or not at all willing?
1.
2.
3.
4.
5.
6.

Q8

Very willing
Somewhat willing
Not very willing
Not at all willing
DK
Refused

(If Q6C = not very willing or not at all willing or DK)
Is there a particular reason why you are unwilling to discuss donation with your family?
1.
2.
3.
4.

Q8A

Yes
No
DK
Refused

(If Q8 = Yes)
What is that reason?
1. [SPECIFY AND RECORD VERBATIM]
2. DK
3. No Reason

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q8B

(If Q8A = “don’t know” or “no reason”)
Would you say it is for one of these reasons? [MULTIPUNCH SELECT ALL THAT
APPLY]
A.
B.
C.
D.
E.
F.
G.
H.
I.

Q9

I don’t want to discuss death with my family
My family wouldn’t understand
My family believes the body should be buried whole
My family is too young to discuss this
I am not in good health
My donor registration is not my family’s business
Whether or not I become a donor is my family’s decision to make
Talking about death may increase the chance of dying
Someone in my family may need my organs

(If Q6B NOT N/A or No Family Members or Q6C NOT N/A or No Family Members)
Has any member or your family told you about his or her wish to donate or not to donate his
or her organs after death?
1.
2.
3.
4.

Q10

Yes
No
DK
Refused

(If Q6B NOT N/A or No Family Members or Q6C NOT N/A or No Family Members)
If you didn’t know your family member’s wishes, how likely would you be to donate his or
her organs upon his or her death, if it were up to you? Would you be very likely, somewhat
likely, not very likely, or not at all likely?
1.
2.
3.
4.
5.
6.

Very likely
Somewhat likely
Not very likely
Not at all likely
DK
Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q11

(If Q6B NOT N/A or No Family Members or Q6C NOT N/A or No Family Members)
If a family member had requested that his or her organs be donated upon death how likely
would you be to donate his or her organs, if it were up to you? Would you be very likely,
somewhat likely, not very likely, or not at all likely?
1.
2.
3.
4.
5.
6.

Q12

Very likely
Somewhat likely
Not very likely
Not at all likely
DK
Refused

Now, I am going to read you a number of statements. For each one, please tell me if you
strongly agree, somewhat agree, somewhat disagree, or strongly disagree.
1.
2.
3.
4.
5.
6.

Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
DK
Refused

A. It is important for a person's body to have all of its parts when it is buried.
B. It is important for people to tell their families whether or not they would want their
organs to be donated upon death.
C. Most members of my family would support the idea of organ donation.
D. Receiving organ transplants improve people’s lives.
E. Organ donation allows something positive to come out of a person's death.
F. A deceased person's next of kin should be able to override the deceased person's wish to
donate his or her organs.
G. Organs should be distributed so that the expected life of the organ is similar to the
expected life of the recipient. For example, older people should generally get older
organs and younger people should get younger organs.
H. All people who need an organ transplant should be able to receive a transplant.

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q14F

Do you believe these statements about organ donation are true?
1.
2.
3.
4.

Yes
No
DK
Refused

A. Kidneys can be donated from a living donor.
B. Parts of livers can be donated from a living donor.
C. Parts of lungs can be donated from a living donor.
Q14E

Have you ever donated an organ or a part of an organ?
1.
2.
3.
4.

Q15

Yes
No
DK
Refused

Assuming you are medically able, how likely would you be to agree to donate an organ
while you are living to [INSERT ROTATED CHOICES]? Would you say very likely,
somewhat likely, not very likely, or not at all likely?
1.
2.
3.
4.
5.
6.

Very likely
Somewhat likely
Not very likely
Not at all likely
DK
Refused

A. A close friend
B. A family member
C. An acquaintance
D. Someone you don’t know
Q15A

(If Q15 = not very likely or not at all likely)
What are your reasons for not agreeing to donate an organ while you are living? [Openended response RECORD VERBATIM]

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q16

Now I am going to read you several statements. For each one, please tell me whether you
strongly agree, somewhat agree, somewhat disagree, or strongly disagree. [ROTATE
STATEMENTS]
1.
2.
3.
4.
5.
6.

Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
DK
Refused

A. Minority patients are less likely to receive organ transplants.
B. You are worried that a loved one's body would be disfigured if his or her organs were
donated.
C. It is possible for a brain-dead person to recover from his or her injuries.
D. People who choose to donate a family member's organs end up paying extra medical
bills.
E. Organ donation helps families cope with their grief.
F. Every year, thousands of people die due to a lack of donated organs for transplantation.
G. If you indicate you intend to be a donor, doctors will be less likely to try to save your
life.
H. A person's wish to donate his or her organs should be honored under all circumstances,
even over the objections of surviving family members.
I. Transplants often go to undeserving people.
J. You would agree to receive an organ transplant if it would save your life.
K. The U.S. transplant system uses a fair approach to distribute organs to patients.
Q16AA

Q16N

[IF Q16A=1,2 ASK Q16AA, ALL OTHERS GOTO Q16N]
Why do you think minority patients are less likely to receive organ transplants? [open ended
response RECORD VERBATIM]
Please choose the statement that comes closest to your view (Rotate)
1. If I were a donor, I would like my organs to go to the more medically urgent patients
regardless of where they live in the U.S., OR
2. If I were a donor, I would like my organs to go to patients in my local area even if they
are not the more medically urgent patients waiting for an organ.
3. DK
4. Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q17

Some countries assume that people will be organ donors upon their death, unless there are
strong objections from the family. This is sometimes called presumed consent. Would you
strongly support, support, oppose, or strongly oppose using this presumed consent approach
in the United States?
1.
2.
3.
4.
5.
6.

Q17A

Strongly support
Support
Oppose
Strongly oppose
DK
Refused

(If Q17 = oppose or strongly oppose)
Is there a particular reason why you oppose presumed consent? [Open-ended response
RECORD VERBATIM]

Q17C

If the United States changed to a presumed consent system, where people will be organ
donors unless they opted out, would you choose to opt out?
1.
2.
3.
4.

Q18

Yes
No
DK
Refused

It has been suggested that more organs would be donated if families who donate the organs
of a deceased loved one received assistance in paying funeral expenses, a cash award to the
donor's estate, or a cash award to a charity of the family's choice. Would payments like
these make you more likely or less likely to donate (read and rotate), or would it have no
effect.
1.
2.
3.
4.
5.

More Likely
Less Likely
No Effect
DK
Refused

A. Your own organs
B. A family member’s organs at their time of death

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q19

(If Q18A or Q18B = more likely)
Is there a particular reason why a payment would make you more likely to donate your
organs or a family member's organs?
1.
2.
3.
4.

Q19A

Yes
No
DK
Refused

(If Q19= Yes)
What reason? [Open-ended response RECORD VERBATIM]

Q20

(If Q18A or Q18B = less likely)
Is there a particular reason why a payment would make you less likely to donate your
organs or a family member's organs?
1.
2.
3.
4.

Q20A

Yes
No
DK
Refused

(If Q20= Yes)
What reason? [Open-ended response RECORD VERBATIM]

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q22

Now I am going to read you several statements. For each one, please tell me whether you
strongly agree, somewhat agree, somewhat disagree, or strongly disagree.
1.
2.
3.
4.
5.
6.

Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
DK
Refused
[ROTATE FOLLOWING CHOICES]

A. Given equal need, a poor person has as good a chance as a rich person of getting an
organ transplant.
B. Doctors do everything they can to save a person's life before organ donation is even
considered.
C. Organ transplantation is an experimental medical procedure.
D. Organ donation is against my religion.
E. It is impossible to have a regular funeral service following organ donation.
F. Many people on the national transplant waiting list die because the organ they need isn’t
donated in time.
Q15E

Recent medical breakthroughs have resulted in successful face and hand transplants for
people who have suffered the loss of limbs or facial disfigurement from traumatic injuries,
such as accidents and war. How willing would you be [INSERT ROTATED CHOICES]?
Would you say you are very willing, somewhat willing, not very willing, or not at all
willing?
1.
2.
3.
4.
5.
6.

Very Willing
Somewhat Willing
Not Very Willing
Not at all Willing
DK
Refused

A. Upon your death to donate your hands
B. Upon your death to donate your face

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q15E1

If your family member signed up to be an organ donor, upon his or her death will you also
be willing to [INSERT ROTATED CHOICES]? Would you be very willing, somewhat
willing, not very willing, or not at all willing?
1.
2.
3.
4.
5.
6.

Very Willing
Somewhat Willing
Not Very Willing
Not at all Willing
DK
Refused

A. Donate your family member’s hands
B. Donate your family member’s face
Q23A

Have you, or has anyone close to you, ever been an organ donor?
1.
2.
3.
4.

Q23B

Have you, or has anyone close to you, ever received an organ transplant?
1.
2.
3.
4.

Q23C

Yes
No
DK
Refused
Yes
No
DK
Refused

Are you, or is anyone close to you, currently waiting for an organ?
1.
2.
3.
4.

Yes
No
DK
Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q26A

Do you believe there is an age when someone is too old to donate an organ upon his or her
death?
1.
2.
3.
4.

Q26A2

Yes
No
DK
Refused

(If Q26A = Yes)
What is that age? [RECORD NUMERIC]

Q26B

Do you believe there is an age when someone is too old to receive an organ?
1.
2.
3.
4.

Q26B2

Yes
No
DK
Refused

(If Q26B = Yes)
What is that age? [RECORD NUMERIC]

Q28

In general, how would you rate your overall health? Would you say excellent, very good,
good, fair, poor?
1.
2.
3.
4.
5.
6.
7.

Excellent
Very Good
Good
Fair
Poor
DK
Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
Q29

What best describes your religion, if any? Would you say Protestant, Evangelical, Roman
Catholic, Orthodox, Mormon, Jewish, Muslim, Buddhist, atheist, agnostic, or something
else?
1. Protestant
2. Evangelical
3. Roman Catholic
4. Orthodox
5. Mormon
6. Jewish
7. Muslim
8. Buddhist
9. atheist
10. agnostic
11. something else
12. DK
13. Refused

Q30

How important are your religious beliefs?
1.
2.
3.
4.
5.
6.

D1

What is your sex?
1.
2.
3.
4.
5.

D2

Very Important
Somewhat Important
Not Very Important
Not at all important
DK
Refused

Male
Female
Other
DK
Refused

What is your age? [RECORD NUMERIC]

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
D3

What is the highest level of education you have completed? [READ CHOICES]
1.
2.
3.
4.
5.
6.
7.
8.

D4A

What is your current marital status?
1.
2.
3.
4.
5.
6.
7.
8.

D7

single/never been married
married
separated
divorced
widowed
domestic partnership/living with partner (not legally married)
DK
Refused

Do you work in the healthcare profession?
1.
2.
3.
4.

D8

less than high school graduate
high school graduate
some college
trade/technical/vocational training
college graduate
post-graduate work/degree
DK
Refused

Yes
No
DK
Refused

What is your zip code?
1. [RECORD 5 DIGIT NUMERIC]
2. DK
3. Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)

D12

Would you describe yourself as Hispanic or Latino Origin?
1.
2.
3.
4.
5.

D11

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin, please specify______________

What best describes your race (can select more than one option)? Would you say [READ
CHOICES]
1. White
2. Black or African American
3. American Indian or Alaska Native please specify____________,
4. Asian Indian
5. Chinese
6. Filipino
7. Japanese
8. Korean
9. Vietnamese
10. Other Asian, please specify ____________
11. Native Hawaiian
12. Guamanian or Chamorro
13. Samoan
6. Other Pacific Islander, please specify_____________

D13

What best describes your current employment status? [READ CHOICES]
1. Employed full-time
2. Employed part-time
3. Taking care of home or family but not working for pay
4. Not employed but looking for work
5. Student
6. Retired
7. Unable to work
8. Other
9. DK
10. Refused

OMB control number 0915-0290 Expiration 09/30/2021

NATIONAL SURVEY OF ORGAN DONATION ATTITUDES AND PRACTICES
Computer-Assisted-Telephone-Interviewing (CATI) Script (English Version)
D14

Do you currently have any type of health insurance plan or health coverage?
1.
2.
3.
4.

D15

Yes
No
DK
Refused

(If D14 = Yes)
What best describes the source of your health plan. If you have more than one, please select
your primary plan. [READ CHOICES]
1. Private plan, such as through an employer
2. The federal insurance exchange at healthcare.gov, or a state insurance plan
3. Medicaid
4. Medicare
5. Veterans’ Affairs
6. TRICARE/Military Health System
7. Other government or state plan
8. Other
9. DK
10. Refused

D9

What is your total ANNUAL household income, before taxes? Please include income from
wages and salaries, remittances from family members living elsewhere, farming, and all
other sources. Please say “yes” when we reach your annual household income.
[READ CHOICES]
1. Less than $20,000,
2. $20,000 or more, but less than $30,000
3. $30,000 or more, but less than $40,000
4. $50,000 or more but less than $60,000
5. $60,000 or more, but less than $75,000
6. $75,000 or more but less than $100,000
7. $100,000 or more, but less than $150,000
8. $150,000 or more
9. DK
10. Refused

Thank you for your participation. Results of the survey will be available in about six months on a
government web site at www.organdonor.gov.