Bereavement Program Survey | CORE | Center for Organ Recovery & Education

Loved one's name*

Date of Birth

Date of Death*

Your name*

Email*

Phone*

What is your relationship to the donor? I am their:*

Other relationship to the donor*

Your loved one was a donor because (check all that apply)*

They made the pledge for life by registering as a donor.
Donation aligns with your loved one’s belief in helping others.
Donation would allow something positive to come out of your loved one’s passing.
You know a transplant recipient or someone waiting for a life-saving transplant.
Donation would allow your loved one’s legacy to live on.
They had previously made their wishes known about donation.
They had prior donation experience.
You had a positive interaction with the CORE representative that you spoke with.
Other (please specify)

Name of CORE representative*

Other reason(s) your loved one was a donor*

Throughout your grief journey, which of the following bereavement resources provided, if applicable, did you find meaningful (check all that apply)*

Sympathy card containing butterfly remembrance pin
Initial letter about the outcome of donation
Requesting an update on the recipients of your loved one’s donation
Follow-up phone call from a Donor Family Services Coordinator
Packet of information including grief material, A Special Place information, and quilt square instructions
Holiday newsletter
Correspondence or meeting a recipient of your loved one’s donation
Holiday Grief Program
Anniversary card

Throughout your grief journey, which of the following bereavement offerings provided, if applicable, did you find meaningful (check all that apply)*

Other bereavement offering(s) you found meaningful*

Have you used any other groups or agencies for bereavement support or counseling services?*

Yes
No

Are there any counseling services that you would recommend for other families?*

Are there any other resources that we may be able to provide to you that will help you on your grief journey?*

It can be meaningful for the public and healthcare professionals to hear your perspective on the affect donation had on you and your family. Would you be interested in sharing your story through our volunteer program?*

Yes, I would be interested.
No, I am not interested at this time.

Would you like for our Donor Family Support Team to contact you regarding your loved one’s donation or for grief support/resources?*

Information regarding your loved one’s donation
Grief support/resources

Overall, on a scale of 1 – 5, with 5 being highly satisfied and 1 being highly dissatisfied, how satisfied are you with the bereavement services provided since the loss of your loved one by our Donor Family Support Team?*