Network Patient Representative Status Questionnaire Survey

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!

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

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

Usually

Sometimes

I have never attended a call.

If yes, what has been most helpful?
If you have never attended, why?

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

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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).

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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).

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

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

Name

Clinic(s)

Home Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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.

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

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

I will work with the clinic staff and ask them to fax them to the Network.

I will mail back the completed questionnaires- please provide a postage paid return envelope.

Other (please specify)