First Name	Last Name
Email	Contact Phone Number

Enter the appropriate answer:

1. When you first arrived at the blood drive, did someone greet you?

Yes No N/A

2. Where you registered within a reasonable amount of time?

Yes No N/A

2.1 If not, did someone on our team recognize you and describe the circumstances?

Yes No N/A

3. Upon completion of the DHF (Donor History Form), were you taken to the screening room within a reasonable amount of time?

Yes No N/A

4. Was the mini physical performed in a professional manner?

Yes No N/A

5. Was the finger stick done well?

Yes No N/A

6. Were you escorted from the screening room to the phlebotomy area?

Yes No N/A

7. Did the phlebotomist acknowledge you?

Yes No N/A

8.Was the phlebotomist professional and attentive to your needs?

Yes No N/A

9. Was the phlebotomy done well?

Yes No N/A

10. Was the refreshments area clean and well stocked?

Yes No N/A

11. Were you thanked for your donation?

Yes No N/A

12. Do you plan to donate blood again when you are eligible?

Yes No N/A

Rate the following statements:

13.1The Blood Bank of Alaska staff were professional, courteous, and knowledgeable.

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

13.2 The High School blood drive was well advertised.

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

13.3 I understand the importance of donating blood for my community.

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

13.4 The MAIN reason I registered to donate blood was because:

I want to save lives
I want the free t-shirt
The Awards/Rewards Program
I want my High School to win the Alaska blood drive challenge

Comments and/or Suggestions:
 

Thank you for giving the Gift of Life and for filling out this questionnaire.

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