Written Testimony Form
Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
Submission Deadline: January 15, 2021
First Name
*
Middle Initial
Last Name
*
Email
*
example@example.com
Credentials
Example: MD, PhD, RD, RN, ANP
Affiliation/Institution:
Company Name
Preferred Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am a:
*
Please Select
Family Member of a Patient
Fellow
Dietitian
Nurse
Nurse Practitioner
Other
Patient
Pharmacist
Physician
Physician Assistant
Resident
Scientist/Researcher
Social Worker
Student (medical, dental, pharmacy, nursing)
Technician
What is your current connection to kidney disease?
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
Setting:
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Academic
Private Practice
Industry
Advocacy
Government
What gender do you identify with?
Please Select
Male
Female
Non-binary
Prefer not to answer
Please select your age range:
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65-75
75-85
85+
Prefer not to answer
How would you describe your race or ethnicity? Please select all that apply.
Hispanic or Latino
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
White or Caucasian
Prefer Not to Say
Other
Testimony
The task force plans to incorporate input into its final report on the inclusion of race in diagnosing kidney diseases.
What topic does your written testimony address?
*
Health Disparities and Equity
Race and Racism
Genetic Ancestry
eGFR estimation (Methods, Populations, etc.)
Standardization and Guidelines
Patients Perspective and Shared Decision Making
Possible Alternative Approaches to Address Race in GFR Estimation
Other
Please use the space below to provide a written testimony to the task force (limited to 500 words).
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