Subject Matter Expert Application Form

Subject Matter Expert Application Form
Subject Matter Experts (SME) are an energetic group of patients, family members, caregivers, and
professionals that help the Network respond to patient needs and seek ways to improve patient/staff
relationships. The SME identifies ways to spread best practices as well as design/implement Quality
Improvement Activities (QIAs) to promote patient-centeredness and family engagement.
Complete the following information:
About You
I am (check one):
___ Patient ___Family/Caregiver ___Stakeholder
If not a patient, is the patient in your life: ___ Adult ___Pediatric (___Age of Pediatric Patient)
Name (First, Last)
Address
City, State, Zip
Primary Phone
Secondary Phone/ Cell Phone
Email Address
Check The Appropriate Selection(s)
____Asian ____White ____Black/African American
I identify as:
____American Indian or Alaska Native
____Native Hawaiian or Other Pacific Islander
Ethnicity: I identify myself as
I speak:
Primary Language Spoken:
About Your ESRD Experience
Dialysis Facility Name
Dialysis Facility Phone Number
Number of years as a dialysis patient
Number of years as a transplant
recipient (as applicable)
Current Treatment Type: (check one)
Previous Treatment Types: (check all
that apply)
Are you on a transplant waitlist? (circle
one)
____Hispanic/Latino ____ Not Hispanic or Latino
____English
___Spanish
Other: __________
____English
___Spanish
Other: __________
____In-Center Hemodialysis: M/W/F or T/T/S
____Peritoneal Dialysis ____Home Hemodialysis
____Transplant
____In-Center Hemodialysis
____Peritoneal Dialysis ____Home Hemodialysis
____Transplant
Yes
No
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Subject Matter Expert Application Form
Connecting With You
How often do you check your email (check
one):
2
____ daily
____ 2-3 times/week
____ only when expecting important messages
____ don’t have email
Yes
No
Are you able to travel for face-to-face
meetings outside of your city or state?
Are you able to attend 2 or more meetings
by phone per year?
Your ESRD Expertise
Why would you like to be a Subject Matter Expert (SME)?
Yes
No
List any of your volunteer organizations, committees, clubs, community groups, etc.
Other interests, hobbies, or skills
Your Interests: Which project(s) would you enjoy working on? (check all that apply)
Patient Advisory Committee (PAC): Advise the Network on issues that affect all the dialysis and
transplant patients in Texas. *(PAC membership requires two letters of reference.)
Patient Grievances: Help improve communication between patients and staff to reduce conflict
Patient Experience of Care (ICH CAHPS): Improve the quality and experience of care across the state
Vascular Access: Help increase fistulas and decrease catheters to improve patient health
Infection Prevention: Contribute ideas on ways to reduce infections, prevent sepsis, and keep patients
healthy
Vaccinations: Share your ideas on ways to encourage patients to accept recommended vaccinations
Home Dialysis: Help the Network understand how to educate patients on home therapy programs
Emergency Preparedness: Help patients learn how to prepare for and respond to an emergency
Other project suggestions:
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Subject Matter Expert Application Form
Please read and check the appropriate statements below:
3
____I authorize AQKC to utilize my name and email address for specific Subject Matter Expert
communications.
____I further authorize AQKC to use my name where necessary in meeting minutes, and in listing SMEs in
reports to The Centers for Medicare and Medicaid Services (CMS).
Signature of Candidate: ______________________________________________Date: ________________
Name of Candidate (print): ______________________________________________
Submit completed form to the appropriate AQKC Network. Allow 5-10 business days for processing
and follow-up.
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