 2) How many times have you donated in the last 12 months?
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1. First time 2. One to Two times a year 3. Three to Four times a year 4. More
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| 3) Did we make you feel valued and appreciated ?
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1. Yes 2. No
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| 4) Please rate the welcome you received upon arrival.
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 5) Was the donor center or blood drive as clean as it should be?
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1. Yes, definitely 2. Yes, somewhat 3. No |
| 6) Please rate the total time you felt you were unnecessarily waiting during the entire donation process.
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5. I did not have to wait unnecessarily 4. Less than 5 min 3. 5 to 15 min 2. 15 to 30 min 1. More than 30 min |
| 7) Please rate the professionalism of our staff.
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied
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| 8) Please rate your overall experience.
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 9) How did you find out about our patient needs and the donation location you visited?
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1. Previously donated or called by center 2. Radio 3. Internet or e-mail 4. Postcard or mailing 5. Other
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| 10) Based on this donation experience, can we count on your generosity for another blood donation in the future?
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1. Yes 2. No (If "No" is selected by Donor they will be asked to provide details of why they will not donate in the
future.) |
| Optional Questions Listed Below (Please select which additional questions you would like for your Center's Survey to include.) |
| 11) Please enter your Visit (Donor ID) number from your receipt. |
| How many digits will the "Donor ID#" be? |
| 12) Please select the Center where you donated blood. |
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(Ex:Enter Location names separated by a comma)
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| 13) Please tell us the name of someone that did a particularly good job? |
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| 14)Please rate the friendliness of our staff. |
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 15) Please rate the refreshments and snacks provided for you. |
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 16) Please rate the fingerstick iron count test. |
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 17) Please rate the privacy of the health and lifestyle questioning. |
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 18) Please rate the insertion of the needle. |
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 19) Please rate the ease of making your appointment |
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5. Totally Satisfied 4. Satisfied 3. Average 2. Dissatisfied 1. Totally Dissatisfied |
| 20) If you made an appointment , was your appointment time honored? |
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1. Yes 2. No 3. Did not make an appointment |
21) How likely are you to recommend this (Name of Blood Center) donation experience to a
friend, co-worker, or family member in the future? |
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5. Very Likely 4. Likely 3. Unsure 2. Not Likely 1. Not at all Likely |
| 22) Did you feel that the blood collection staff was skilled and competent? |
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1. Yes, definitely 2. Yes, sometimes 3. No |
| 23) Did the blood collection staff talk in front of you as if you weren't there? |
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1. Yes, often 2. Yes, sometimes 3. No |
| 24) How well organized was the donor center or the blood drive? |
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1. Very organized 2. Somewhat organized 3. Not at all organized |
| 25) Why did you decide to donate today? |
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1. Help others 2.Gives me personal satisfaction 3. Do my part for the community 4. Civic/charitable responsibility 5. Saves lives |
| 26) Will you donate again in the next 6 months? |
1. Yes, definitely 2. Yes, probably 3. No
(If "No" is selected by Donor they will be asked to provide details of
why they will not donate in the next 6 months.) |
| 27) For future use |
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| 28) Were refreshments offered to you at the end of your donation? |
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1. Yes 2. No |
| 29) Did staff thank you for giving blood? |
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1. Yes 2. No |
| 30) Did the blood collection staff explain the blood donation process to your satisfaction? |
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1. Yes, definitely 2. Yes, somewhat 3. No |
31) Did the blood collection staff explain what to do if you experienced problems after your blood
donation? |
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1. Yes, completely 2. Yes, somewhat 3. No |
| 32) Please make any additional comments about your donation. |
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