Are you a registered organ donor?
I'm Anissa Durham the health data reporter at Word In Black. I'm working on a story about the disconnect some Black folks have about registering as an organ donor. I have heard rumors about why some are uncomfortable doing so and I'm interested to further investigate why that is.
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Name
Age *
City, State *
Racial & Ethnic Identity (Please check all that apply) *
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Are you a registered organ donor? *
If you selected yes, why did you decide to register as a donor?
If you selected no, why did you decide not to register as a donor?
Have you ever heard or been told that by registering as an organ donor, U.S. hospitals would not save you in the event that your life is in danger? *
What would you like to know about the organ donation process? *
Would you be willing to be interviewed by Word In Black health data reporter Anissa Durham? *
Please leave your contact information, so she can reach out to you. Or email her at anissa.durham@localmedia.org.
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