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Kidney Basics
Treatment & Support
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Get Involved
Peer Supporter Application
Basic Information
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MI
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Do you have access to the following (select all that apply)?
A Smart Phone
A Computer (with internet access)
None
Best Time to be Reached
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Morning
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Connection to Kidney Disease
What is your current connection to kidney disease?
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I am a kidney patient
I am a living donor
Type of Connection
Please select...
I am at risk for kidney disease
I have CKD Stage 1 or 2
I have CKD Stage 3
I have CKD Stage 4 or 5 and not on dialysis
I am on dialysis
I am a transplant recipient
I have kidney cancer
I have kidney stones
Have you received a transplant from (select all that apply):
Living Donor
Deceased Donor
Dialysis Type
Please select...
Home Hemodialysis
Hemodialysis
Nocturnal Hemodialysis
Peritoneal
For How Many Years have you been on dialysis?
In the past were you any of the following? (Check all that apply)
Hemodialysis Patient
Peritoneal Dialysis Patient
Home Hemodialysis Patient
Nocturnal Hemodialysis
Transplant Recipient
None of the Above
For How Many Years Were You on Dialysis/Had Your Transplant?
For How Many Years Have You Been a Kidney Patient?
What is the cause of your kidney disease
Please select...
Acute Kidney Injury
Age-related
Alport's Syndrome
C3G
Diabetes Type 1
Diabetes Type 2
Fabry
FSGS
Glomerulonephritis
Goodpasture's Syndrome
High Blood Pressure
HIV/AIDS
IGA Nephropathy
Kidney Stones
Lupus
Membranoproliferative Glomerulonephritis
Membranous Nephropathy
Minimal Change Disease
Polycystic Kidney Disease (PKD)
Primary Distal Renal Tubular Acidosis
UTIs
Demographic Information
What of these best describes how you spent most of your time during the past 4 weeks?
Full-time employee
Part-time employee
Student
Homemaker
Volunteer
Retired
Retired due to disability
Unemployed/Looking for work
Do not want to answer
What is the highest grade or year of school you have completed?
Please select...
Elementary (1-5)
Intermediate or Middle School (6-8)
High School (9-12) or GED
Some college but did not graduate
College
Graduate or Professional School
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How many people are currently living in your household, including yourself?
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1
2
3
4
5
6
7
8+
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What is your current marital status?
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Single/never married
Married/living together
Divorced
Separated
Widowed
Do not want to answer
What is your race?
Please select...
African American/Black
Asian/Pacific Islander
American Indian/Alaskan
Caucasian
Mixed Race
Other
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If other or mixed race, which race(s) do you identify with?
Are you of Hispanic or Latino(a) origin or decent, such as Mexican, Puerto Rican, Cuban, or other Spanish background?
Please select...
Yes
No
Do not want to answer
More Information
Why do you want to be a mentor?
Please use this space to tell us more about yourself and your experiences with kidney disease, donation or transplant. If you are a kidney patient, tell us about when you were diagnosed and your journey with kidney disease. What was the hardest part? What surprised you? If you are a living donor please describe how you came to be a living donor and who you donated to.
If you could tell someone new to the disease ONE thing that you wish you had known at the start, what would that one thing be?
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