Anonymous Pre-Screening Questionnaire – Heart of the Motor Film

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Anonymous Pre-Screening Questionnaire – Heart of the Motor Film

For research and impact purposes, Donate Life Kentucky Trust is tracking information before and after viewing this film. Please select your best answer for each question. There are no trick questions.

We hope you enjoy the film and look forward to your feedback.

What does it mean to be an organ donor? *

To give blood during surgery

To donate organs after death to help others live

To donate your body to science or medical research

To receive an organ transplant

True or False: One organ donor can save or improve lives *

True

False

When does organ donation usually happen? *

Only if a person is very old

Only when someone is alive

After death, when certain medical criteria are met

Who makes the final decision about organ donation if someone is under 18?

The hospital

The family or legal guardian

The Donor Registry

Other:

Clear selection

Do you know anyone in your community who has received an organ transplant or donated organs? *

Yes

Maybe

Other:

What is one reason people choose to become organ donors? *

To help others live longer and healthier lives

To receive money

Because hospitals require it

On a scale from 1 to 10, how likely are you to join the Donor Registry when you get your driver's license or online? *

Extremely unlikely to register

Extremely likely to register

Are you already registered as an organ donor? *

Yes

Maybe

Other:

Any additional information or questions?

If you're passionate about the mission, please apply for our Donate Life scholarship by April 6, 2026! No GPA or extracurricular activities required - just 3 questions. Learn more www.donatelifeky.org or call/text us 502-694-3015.

Following questions are optional & for research purposes only:
What is your age? (optional)

Which COUNTY do you live in? (such as: Pike, Jefferson, Daviess, Fayette, etc.)

Gender (optional)

Female

Male

Non-binary / Another gender

Prefer not to say

Other:

Race or ethnicity (optional)

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White

American Indian or Alaska Native

Multiracial / More than one race

Prefer not to say

Other:

Clear selection

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