MEI Dialysis Decision Aid Feedback Form

A self-assessment administered to dialysis facility professionals to gauge feedback on the usefulness and effectiveness of the MEI Dialysis Decision Aid.

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* 1. Enter the name of your facility?

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* 2. Enter your facility's 6-digit CMS Certification Number (CCN).

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* 3. How user-friendly did you find MEI Dialysis Decision Aid to be?

Very User Friendly

Somewhat User Friendly

Not User Friendly At All

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* 4. Did you learn anything new about home therapy modalities as a result of testing the MEI Dialysis Decision Aid?

Yes

If yes, please describe:

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* 5. Do you think the language and wording used in the MEI Dialysis Decision Aid is adequate for your patients reading and health literacy level?

Yes

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* 6. What percentage of your patient population do you believe have internet access or a mobile device to utilize the MEI Dialysis Decision Aid online?

Most - Over 50%

Many - 40% - 50%

Not Many - Less than 40%

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* 7. Do you believe that the MEI Dialysis Decision Aid will serve as a conversation starter that will lead to patients wanting more information about home therapies?

Yes

No - If no, please briefly describe why you don't think the Aid will be a conversation starter.

If no, please describe:

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* 8. Do you think this tool could be used to help generate home therapy referrals in your facility?

Yes

No - If no, please briefly describe why not.

If no, pease describe: