Contact Info and Interest Survey
IROC Community Engagement Workgroup
Email address *
Name *
Your answer
Phone *
Your answer
Mailing Address *
Your answer
Hospital Name *
Your answer
Are you a kidney recipient?
Were you or do you plan to be a kidney donor?
Patient Name
Your answer
What is your relationship to the patient? *
Patient Date of Birth
MM
/
DD
/
YYYY
Year of Patient's Transplant
MM
/
DD
/
YYYY
What is your relationship to kidney care? *
Why are you interested in helping IROC? *
Your answer
What do you hope to gain from your participation in IROC? *
Your answer
Please list the specific medical experience you can offer to IROC (eg., PD, HD, NG-tube, g-tube, PKD, PUV, ureterostomy, port, OT, PT, etc.)?
Your answer
What areas are you interested in working on within the Community Engagement Workgroup?
I am interested in working on...
Patient Quality of Life Improvement
Patient and Family Roadmap to Transplant
Patient and Family Mentoring Program
Fundraising
IROC Priority Special Projects
Other
What is your profession?
Your answer
Do you have any personal/professional skills you would like to share?
Your answer
Do you have any additional ideas for Community Engagement projects?
Your answer
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