Thank for taking the time to give us your feedback. In this questionnaire, we are asking you to:

1) share information about your clinic's use of the Network resources, what activities you have been involved in with your clinic and what the Network can do to support you in your role as NPR; and

2) assist with distributing questionnaires from patients at your clinic.

 
Thank you for all you do!
Please answer the following questions regarding the clinic you represent.

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* 1. Please answer the following questions regarding the clinic you represent.

  Yes No
The clinic has the MY KIDNEY KIT in a place that is accessible to patients.
The clinic uses the MY KIDNEY KIT in their patient education.
The clinic offered a copy of the MY KIDNEY CALENDAR to all patients.
The clinic has a copy of the MY KIDNEY CALENDAR in a location which encourages them to discuss the weekly tips or monthly topics.
The clinic uses the MY KIDNEY CALENDAR monthly topic to educate patients.
The clinic representative (social worker/nurse manager) talks with me on a regular basis and seeks my ideas on ways to help patients.
The clinic is involved in one of the Network Quality Improvement Activities.
The clinic has invited me to be a part of their quality improvement team meetings.
The clinic posts and/or offers copies of the Heartland Headlines patient newsletter.
How often do you attend the NPR Connection Calls? (Held every other month)

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* 2. How often do you attend the NPR Connection Calls? (Held every other month)

What topics would you like to learn more about on the connection calls?

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* 3. What topics would you like to learn more about on the connection calls?

Mark the number of "thumbs up" that best represents how active you have been in your role as NPR, (0= no activities 5 = very active).

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* 4. Mark the number of "thumbs up" that best represents how active you have been in your role as NPR, (0= no activities 5 = very active).

Please share an example of an activity that you have done with your clinic (For example: welcomed a new patient or helped give ideas for a bulletin board).

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* 5. Please share an example of an activity that you have done with your clinic (For example: welcomed a new patient or helped give ideas for a bulletin board).

What else can the Network do to support you in your role as NPR?

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* 6. What else can the Network do to support you in your role as NPR?

Please provide your name, address and the name of the clinic or clinics you represent.

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* 7. Please provide your name, address and the name of the clinic or clinics you represent.

PART 2: We would like your assistance to distribute and collect a questionnaire to the patients at the clinic(s) you visit to find out how they have used the MY KIDNEY CALENDAR and share any actions they have taken since January.
Please indicate the number of printed My Kidney Calendar feedback questionnaires you would like sent to you. (50 max)

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* 8. Please indicate the number of printed My Kidney Calendar feedback questionnaires you would like sent to you. (50 max)

Please indicate how you would like to return the questionnaires to the Network.

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* 9. Please indicate how you would like to return the questionnaires to the Network.

Thank you for your feedback and help with this process.

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