you answer these questions, think only about your experience at [SAMPLE FACILITY NAME], even if In the last 3 months, when you you have not been receiving care arrived on time, how often did there for the entire 12 months. you get put on the dialysis machine within 15 minutes of You can treat kidney disease your appointment or shift time? with dialysis at a center, a 1 Never kidney transplant, or with 2 Sometimes dialysis at home. In the last 12 3 Usually months, did your kidney doctors 4 Always or dialysis center staff talk to you as much as you wanted In the last 3 months, how often about which treatment is right was the dialysis center as clean for you? as it could be? 1 Yes 1 Never 2 No 2 Sometimes 3 Usually Are you eligible for a kidney 4 Always transplant? 1 Yes If Yes, Go to Using any number from 0 to 10, Question 39 where 0 is the worst dialysis 2 No center possible and 10 is the 3 I know If don’t Don’t Know, best dialysis center possible, Go to Question 39 what number would you use to rate this dialysis center? In the last 12 months, has a 0 0 Worst dialysis center doctor or dialysis center staff possible explained to you why you are 1 1 not eligible for a kidney 2 2 transplant? 3 3 1 Yes 4 4 2 No 5 5 6 6 7 7 Peritoneal dialysis is dialysis 8 8 given through the belly and is 9 9 usually done at home. In the last 10 10 Best dialysis center 12 months, did either your possible kidney doctors or dialysis center staff talk to you about peritoneal dialysis? 1 Yes The next few questions ask about 2 No your care in the last 12 months. As
In the last 3 months, when you arrived on time, how often did you get put on the dialysis machine within 15 minutes of your appointment or shift time? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often was the dialysis center as clean as it could be? 1 Never 2 Sometimes 3 Usually 4 Always Using any number from 0 to 10, where 0 is the worst dialysis center possible and 10 is the best dialysis center possible, what number would you use to rate this dialysis center? 0 0 Worst dialysis center possible 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 Best dialysis center possible The next few questions ask about your care in the last 12 months. As you answer these questions, think only about your experience at [SAMPLE FACILITY NAME], even if you have not been receiving care there for the entire 12 months. You can treat kidney disease with dialysis at a center, a kidney transplant, or with dialysis at home. In the last 12 months, did your kidney doctors or dialysis center staff talk to you as much as you wanted about which treatment is right for you? 1 Yes 2 No Are you eligible for a kidney transplant? 1 Yes If Yes, Go to Question 39 2 No 3 I don’t know If Don’t Know, Go to Question 39 In the last 12 months, has a doctor or dialysis center staff explained to you why you are not eligible for a kidney transplant? 1 Yes 2 No Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 12 months, did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis? 1 Yes 2 No