Form Due by May 14, 2020

Please submit only one report per facility.  Data on your submission should reflect what happened in the month of April 2020.

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* 2. Enter your name and phone number.

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* 3. How many VR eligible patients do you currently have in your facility in the reporting month?
(enter numerical value)
-- Eligibility Criteria for VR:  (1) Between 18 through 54 years of age; (2) Blind or have a disability AND receive SSDI or SSI benefits; (3) not currently employed, in school, or receiving specialized training

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 4. How many patients between 18 and 54 years of age, if any, have you referred to VR or EN services in the reporting month?

0 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 5. How many patients between 18 and 54 years of age, if any, had an appointment with VR/EN during the reporting month -- including telephone and virtual check ins?

0 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 6. How many patients between 55 and 64 years of age has an appointment with Employment Network (or Vocational Rehabilitation) services this month -- including telephone and virtual check ins?

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.
Patient and Family Engagement Assessment
Facilities will include patients and/or family members/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body 

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* P1. Does your facility include patients and/or family members/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body of the facility?

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* P2.  My facility took the following actions to impact this goal during the reporting month:

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* P3.  What other resources would be helpful for you to meet the PFE Goals?
(please include your name and email address so we can follow up with you)

Resource / Activity Review -- For April Reporting

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* R1.  Did you, or someone from your facility staff, attend the "Supporting Gainful Employment" webinar, with guest speaker: the National Employment Network Association (NENA)?
The webinar was hosted by Qsource ESRD Networks on April 30.  Here is a link to the recording:  https://attendee.gotowebinar.com/recording/38308491222459650

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How to Check Your Patient Roster

How to Check Your Patient Roster

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* R2. Rate the benefits of the resource tool -- How to Check Your Patient Roster (in CROWNWeb)
(select all that apply)

Monthly Wrap Up

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* What support do you need from your ESRD Network to help with the Vocational Rehabilitation QIA initiative? (please include your name and email address so we can follow up with you)

T