Final Report Public Comment Form
Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
First Name
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Middle Initial
Last Name
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Email
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example@example.com
Credentials
Example: MD, PhD, RD, RN, ANP
Affiliation/Institution:
Company Name
Preferred Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am a (check all that appy):
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Family Member of a Patient
Fellow
Dietitian
Nurse
Nurse Practitioner
Patient
Pharmacist
Physician
Physician Assistant
Resident
Scientist/Researcher
Social Worker
Student (medical, dental, pharmacy, nursing)
Technician
Other
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?
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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
Please use the space below to provide your comments on the Task Force's Final Report.
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