Patient Advisory Council (PAC) and Subject Matter Expert (SME) Application Form

ABOUT YOU

I am a (check one):

Patient

Family/Caregiver

Stakeholder

Name (First, Last)

Address

City

State

Zip

Primary Phone Number

Email Address

Race

I identify as:

American Indian or Alaska Native

Asian

Black/African American

Native Hawaiian or Other Pacific Islander

White

Other

If you selected Other, please specify:

Ethnicity

I identify myself as:

Hispanic/Latino

Not Hispanic or Latino

Language

I mainly speak:

English

Spanish

Other

If you selected Other, please specify:

About Your ESRD Experience

Dialysis Facility Name

Dialysis Facility Phone Number

Name of Referring Staff Member

(must be included if staff member is referring candidate)

Number of Years as a Dialysis Patient

Current Treatment Type

Please Check One:

In-Center Hemodialysis

Peritoneal Dialysis

Home Hemodialysis

Transplant

If you are an In-Center patient, please choose your treatment days:

M/W/F

T/T/S

If you are a transplant Patient, please tell us how many years you have had a transplant:

Previous Treatment Types: (check all that apply)

In-Center Hemodialysis

Peritoneal Dialysis

Home Hemodialysis

Transplant

Are you on the Transplant Waitlist?

Please choose one:

Yes

Connecting with You

Please choose preferred method of contact:

Phone

Mail

How often do you check your email:

Please check one:

Daily

2-3 time/week

Only when expecting important messages

Don't have email

Are you able to attend 2 or more meetings by phone per year?

Yes

Please read the following statements:

(all must be checked to be considered) PAC member responsibilities can be found here: http://www.esrdnetwork10.org/patients/patient-advisory-council/

I have read the PAC member responsibilities and participation/membership policy and agree to fulfill them to the best of my ability.*

I authorize Qsource ESRD Network 10 and my dialysis center (if applicable) to utilize my name and email address for specific PAC and SME communications.*

I further authorize my Network to use my name where necessary in PAC and SME meeting minutes and in listing PAC and SME members in reports to the Centers for Medicare and Medicaid Services (CMS) and other business documentation.*

Applicant Signature:

Please type in name

Date:

Staff Signature (if Applicable):

Please type in name

Date:

Send me a copy of my responses

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