KCER Patient Needs Assessment (Hemodialysis) - February 2017

Coordinated by the Kidney Community Emergency Response (KCER) Program

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* 1. Please name the state or territory where you receive your dialysis treatment:

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* 2. Number of years on dialysis:

Less than one year

1–5 years

6–10 years

More than 10 years

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* 3. What is your treatment modality:

In-center hemodialysis

Home hemodialysis

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* 4. Education level:

Middle School

High School

Some College

College Graduate

Technical Training or Certificate Program

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* 5. Does your facility provide emergency preparedness information in a language you can understand?

Yes

If "no", what language do you need?

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* 6. How many times in the last year have you received information on emergency preparedness from your clinic?

One time

Two times

Three times

More than three times

I have not received any emergency preparedness information from my clinic in the last year.

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* 7. If you received information on emergency preparedness from your clinic, please indicate which topics were included. (Check all that apply):

What to do in an emergency, both in and out of the facility

Where to go in an emergency

Whom to contact in an emergency

How to disconnect from the dialysis machine if an emergency occurs in the clinic

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* 8. What is the best way to give you information about emergency preparedness? Please rank your selections from most preferred to least preferred.

Video

Written (i.e., flyer, handout, booklet)

Face-to-face (i.e., talking with staff, doctor, or other patients)

Internet (i.e., website or email)

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* 9. Have you ever experienced an emergency or disaster that made you miss or skip a treatment?

Yes

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* 10. If you have skipped or missed a treatment due to an emergency or disaster, did you go to the hospital due to the skipped or missed treatment?

Yes

N/A

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* 11. Do you have plans to leave your home and go somewhere safe if an emergency happens?

Yes

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* 12. If yes, have you shared your emergency plan with friends or relatives?

Yes

N/A

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* 13. Please check the box next to each item that you have available to take with you on short notice.

Health and prescription insurance information

A detailed list of your medications

An extra two-week supply of medications

A list of dialysis centers where you could receive treatment

A copy of your medical records, including dialysis treatment information

Most recent plan of care

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* 14. Do you understand how to follow the 3-day emergency renal diet?

Yes

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* 15. Are you aware of medications that can help reduce your potassium level, such as Kayexalate?

Yes

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* 1. Please name the state or territory where you receive your dialysis treatment:

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* 2. Number of years on dialysis:

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* 3. What is your treatment modality:

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* 4. Education level:

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* 5. Does your facility provide emergency preparedness information in a language you can understand?

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* 6. How many times in the last year have you received information on emergency preparedness from your clinic?

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* 7. If you received information on emergency preparedness from your clinic, please indicate which topics were included. (Check all that apply):

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* 8. What is the best way to give you information about emergency preparedness? Please rank your selections from most preferred to least preferred.

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* 9. Have you ever experienced an emergency or disaster that made you miss or skip a treatment?

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* 10. If you have skipped or missed a treatment due to an emergency or disaster, did you go to the hospital due to the skipped or missed treatment?

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* 11. Do you have plans to leave your home and go somewhere safe if an emergency happens?

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* 12. If yes, have you shared your emergency plan with friends or relatives?

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* 13. Please check the box next to each item that you have available to take with you on short notice.

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* 14. Do you understand how to follow the 3-day emergency renal diet?

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* 15. Are you aware of medications that can help reduce your potassium level, such as Kayexalate?

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* 16. Please add any additional comments you would like to share: