Organ Donation Name Age Sex Male Female Your Address Your E-mail Your Mobile Qualification Occupation Please Select Housewife Govt. Service Private Service Other QUESTIONNAIRE 1. Are you aware that organs can be donated to save a life of another person? Yes No No idea 2. Can organ donation take place at any age? Yes No No idea 3. When can organs be donated? During life After death both 4. Can organ donation take place if the donor has a chronic disease such as diabetes? Yes No No idea 5. Which organs can be donated? Eye Skin Heart Lungs Pancreas Kidney Bones Liver All 6. Can organ donation take place despite wearing glasses? Yes No No idea 7. Do you know someone whose organs have been donated? Yes No 8. Can a person with cancer be an organ donor? Yes No No idea 9. Do you know of a law in India recognizing brain death for organ donation? Yes No No idea 10. Are you willing to an organ donor after death? Yes No 11. If you had to decide, would you agree to donate organs of a brain dead person you know? Yes No No idea 12. Do you carry an organ donor card always to show that you are a registered organ donor? Yes No 13. Are you interested in getting more information on organ donation? Yes No No idea 14. Do you know of a person close to your who has been advised a transplant. Yes No Submit
