Living Donors Online!

a. What is your name? Required

b. What is your gender? Female Male Not disclosed

c. What is your marital status? Single Married Not disclosed

d. Where do you live (city, state/province, country)? Required

e. What did you donate? Kidney Liver Lung Bone Marrow Other Required
>> If "Other," please specify what you donated:

f. To whom did you donate (for example, son, sister, parent, cousin, or unrelated)?

g. Was the recipient an adult or child? Adult Child Don't know

h. What was the date of donation? January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

i. At what transplant facility or hospital did you donate?

j. Answer this question only if you donated a kidney. All other donors should skip to question k.

What surgical procedure was used to remove your kidney? Open nephrectomy Laparoscopic nephrectomy I don't know Other
>> If "Other," please describe the procedure:

k. Have you received any formal training to be a counselor or mentor to living donors?
Yes No

l. How would you rate your donation experience? Required
Very positive
Mostly positive
Partially positive and partially negative, or neutral
Mostly negative
Very negative

m. What is your email address? Required

Remember to include your full email address including the domain name, for example, my_email@aol.com. Your email address will not be disclosed in the Living Donor Buddy entry to protect your privacy. It will be shared only with potential donors interested in contacting you.

n. Describe the reasons why someone would want you as their Living Donor Buddy:
Required

2. Submit Your Entry

"I attest that the information above is accurate, complete, and timely, and that I have read, understand, and accept the Living Donor Buddy Participant Agreement."

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