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

Loved One's Name:*

Loved One's Date of Birth:

Loved One's Date of Death:*

Your Name:*

Your Email:*

Your Phone:*

Please tell us how you’re related to the donor. You are their:*

Other relationship to the donor:*

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

Your loved one made the pledge for life by signing up as a donor.
Donating reflects your loved one’s values of helping others.
Donation would allow something positive to come out of your loved one’s passing.
You know someone who has either received a life-saving transplant or is waiting for one.
Donation would allow your loved one’s legacy to live on.
Your loved one had expressed their wishes regarding donation.
Your loved one had an experience with donation in the past.
You had a positive interaction with your CORE representative(s).
Other (please specify)

Name of CORE representative:*

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

Which Bereavement Resources were Most Supportive and Meaningful to You During Your Grief Journey (Check All That Apply):*

Sympathy card containing butterfly remembrance pin.
First letter which included details about the outcome of your loved one’s donation.
Packet of information including grief material, A Special Place information, and quilt square instructions.
Holiday newsletter.
Holiday Grief Program.
Anniversary card.

Have You Engaged in Any of the Following Bereavement Support Services, and Which did You Find Meaningful (Check All That Apply):*

Use of the donor emblem in your loved one’s obituary.
Attendance at CORE’s A Special Place donor remembrance ceremony and memorial.
CORE’s volunteer program.
The Gallery of Heroes online donor memorial.
The CORE Donor Family Facebook Group.
Online grief support/webinars.
Other (please specify)

Other Bereavement Support Services(s) You Found Meaningful:*

Hidden

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

Yes
No

When you spoke with the CORE representative, either in person or on the phone, did you feel they were compassionate and supportive?*

Yes
No

Comments regarding CORE representative you spoke with:

CORE provides many ways for donor families to honor their loved ones. As a CORE Advocate, you can do this while also promoting the cause of organ, tissue, and cornea donation. Would you like to learn more about our Volunteer Program?*

Yes
No

Would you like a member of CORE’s Donor Family Support Team to reach out to you for grief support or with additional bereavement resources?*

Yes
No

Would you like a member of CORE’s Donor Family Support Team to reach out to you regarding your loved one’s donation?*

Yes
No

Hidden

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

Beyond the resources provided by CORE, were there any other services or offerings that supported you physically and emotionally, which you would recommend we consider adding to our program for other donor families?*

Are there any other resources that CORE can offer you now and in the future to support you on your grief journey, or that would have been useful to you while grieving over the last 13 months?*

Overall, how satisfied are you with the bereavement services provided since the loss of your loved one by our Donor Family Support Team? (1 - Highly Dissatisfied; 10 - Highly Satisfied)*

Comments

This field is for validation purposes and should be left unchanged.