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UNDERSTANDING DONATION
Donation Process
Dispelling the Myths
Donation for Research
Living Donation
Donor Families
Donor Family Support
Navigating Your Grief
CORE Remembrance Quilt
A Special Place Ceremony
Brian A. Broznick Bereavement Center & Garden
Recipients
The Waiting List
Writing to Donor Families
Team Alleghenies Transplant
Recipient Resources
Community
Stories of Heroes
Show Your Support
Community Education
Request Educational Support
Download Brochures
Partners
Volunteer
Volunteer Application
Calendar of Events
Resource Request Forms
Professionals
Clinical Researchers
Donor Referrals
Eye Bank
Hospital Resources
Medical Examiners & Coroners
Funeral Directors
About Us
Careers
Newsroom
Contact Us
REGISTER
PA
WV
About Us
Careers
Newsroom
Contact Us
REGISTER
PA
WV
UNDERSTANDING DONATION
Donation Process
Dispelling the Myths
Donation for Research
Living Donation
Donor Families
Donor Family Support
Navigating Your Grief
CORE Remembrance Quilt
A Special Place Ceremony
Brian A. Broznick Bereavement Center & Garden
Recipients
The Waiting List
Writing to Donor Families
Team Alleghenies Transplant
Recipient Resources
Community
Stories of Heroes
Show Your Support
Community Education
Request Educational Support
Download Brochures
Partners
Volunteer
Volunteer Application
Calendar of Events
Resource Request Forms
Professionals
Clinical Researchers
Donor Referrals
Eye Bank
Hospital Resources
Medical Examiners & Coroners
Funeral Directors
About Us
Careers
Newsroom
Contact Us
REGISTER
PA
WV
Bereavement Program Survey
Bereavement Program Survey
"
*
" indicates required fields
Loved One's Name:
*
Loved One's Date of Birth:
MM slash DD slash YYYY
Loved One's Date of Death:
*
MM slash DD slash YYYY
Your Name:
*
Your Email:
*
Your Phone:
*
Please tell us how you’re related to the donor. You are their:
*
Select...
Spouse
Child
Parent
Sibling
Other
Other relationship to the donor:
*
You and Your Loved One Said 'Yes' to Donation 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.
You know someone who has either received a life-saving transplant or is waiting for one.
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.
Ability to request an update on the recipients of your loved one’s donation.
The phone call from CORE donor family services team member after your loved one’s passing.
Packet of information including grief material, A Special Place information, and quilt square instructions.
Holiday newsletter.
Holiday Grief Program.
Anniversary card
Correspondence or meeting a recipient of your loved one’s donation.
None of the above.
Have You Engaged in Any of the Following Bereavement Support Services, and Which did You Find Meaningful (Check All That Apply):
*
Framed "My Final Gift" poem.
The 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 offering(s) you found meaningful
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
This field is hidden when viewing the form
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)
*
1
2
3
4
5
6
7
8
9
10
Comments
This field is for validation purposes and should be left unchanged.
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