GiftWorks Patient Onboarding Questionnaire

Recipient Readiness Application
Important — Please Read Before Continuing

This application is for kidney transplant recipients who are interested in participating in the GiftWorks Program.

If you are completing this application on behalf of a recipient (for example, as a family member), please confirm that:

• The recipient wants to participate in the GiftWorks Program.
• The recipient is aware this application is being submitted.
• All answers are provided from the recipient’s perspective.

If the recipient has not reviewed or approved of this application, please pause and speak with them before continuing.
I am the kidney recipient.I am completing this application with the recipient’s knowledge and consent, and all answers reflect the recipient’s wishes.
Patient's Full Name*
Patient's Email Address*
example@example.com
Patient's Date of Birth*

MonthDayYear
Patient's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemale
SingleMarriedDomestic partnershipDivorcedSeparatedWidowedPrefer not to say
YesNoPrefer not to answer
EmployedNot EmployedRetired
EnglishSpanishOther
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherPrefer not to sayOther
We ask this question for internal program evaluation and equity analysis only. Your response will not affect eligibility, readiness scoring, selection, or participation in the GiftWorks Program. Answering is optional.
Not on dialysisOn dialysis less than 1 yearOn dialysis 1-3 yearsOn dialysis more than 3 years
Less than a year1-2 years2-3 yearsMore than 3 years
NoYes
I can consistently commit 2-3 hours every weekI can commit 2-3 hours most weeks, but may occasionally miss a weekI'm unsure I can commit 2-3 hours per week on an ongoing basis
Complete weekly activitiesAttend group learning sessionsStay actively engaged in your search for a living donorShare your need for a living donor publicly with those you know
YesMaybeNo
Why is finding a living kidney donor important to you right now, and what are you willing to do to make that happen? (3-6 thoughtful sentences is perfect.)
I post or share content at least weeklyI post or share content occasionally (1-2 times per month)I rarely post, but I am willing to share when guidedI do not use social media
I have already asked people to help support or share my search in the past few monthsI haven't asked yet, but I am willing to learn how and tryI am not comfortable asking others to help support or share my search right now
When you need help, how comfortable are you asking others for support?*

1

2

3

4

5

6

7

8

9

10

1 is Very Uncomfortable, 10 is Very Comfortable
When it comes to your living donor search, how comfortable are you sharing your need publicly. For example, on social media, by email or text, or within your community?*

1

2

3

4

5

6

7

8

9

10

1 is Very Uncomfortable, 10 is Very Comfortable
Yes, publicly (ex: social media, email, events)Yes, privately (ex: one on one conversations)No
YesMaybeNo
Partner/SpouseAdult childrenFriendsReligious or community groupsCoworkersOther
YesMaybeNo
YesNoI'm not sure
Not sure12-56 or more
Program Participation Acknowledgment & Commitment
I understand that, if accepted into the GiftWorks Program, I will be asked to actively participate in sharing my search for a living donor with my community. This may include sharing on my social media platforms and communicating directly with people I know.

I understand that my involvement and engagement are critical to the success of this program.

I agree to actively engage with the GiftWorks team, follow program guidance, and seek appropriate opportunities to share my search for a living donor with my network.

I understand that participation in the GiftWorks Program requires a time commitment of approximately 2–3 hours per week, which may include completing activities, attending online education sessions, and participating in group discussions.
I acknowledge and agree
Should be Empty:

Recipient Readiness Application

Program Participation Acknowledgment & Commitment