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KCER Patient Needs Assessment (Peritoneal) - February 2017
Coordinated by the Kidney Community Emergency Response (KCER) Program
1.
Please name the state or territory where you receive your dialysis treatment:
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2.
Number of years on dialysis:
Less than one year
1–5 years
6–10 years
More than 10 years
3.
What is your treatment modality:
Continuous cycling peritoneal dialysis (CCPD)
Continuous ambulatory peritoneal dialysis (CAPD)
4.
Education level:
Middle School
High School
Some College
College Graduate
Technical Training or Certificate Program
5.
Does your clinic provide emergency preparedness information in a language you can understand?
Yes
No
If "no", what language do you need?
6.
How many times in a 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.
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 clinic
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
8.
What is the best way to give you information about emergency preparedness? Please rank your selections.
1
2
3
4
Video
Written (i.e. flyer, booklet, handout)
Face-to-Face (i.e. talking with staff, doctor, or other patients)
Internet (i.e. website or email from facility)
9.
Have you ever experienced an emergency or disaster that made you miss or skip a treatment?
Yes
No
10.
If you've missed or skipped a treatment due to an emergency or disaster, did you go to the hospital due to the skipped or missed treatment?
Yes
No
N/A
11.
Do you have plans to leave your home and go somewhere safe if an emergency happens?
Yes
No
12.
If yes, have you shared your emergency plan with friends or relatives?
Yes
No
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
14.
Do you know how to operate your PD/Home Dialysis Unit in case of power loss?
Yes
No
15.
Do you know how to order extra supplies?
Yes
No
16.
Do you have an extra supply of antibiotics at home?
Yes
No
17.
Do you understand how to follow the 3-day emergency renal diet?
Yes
No
18.
Are you aware of medications that can help reduce your potassium level, such as Kayexalate?
Yes
No
19.
Please add any additional comments you would like to share:
