KIDNEY HEALTH EXPERT PATIENT ADVOCACY ACADEMY NOMINATION FORM

Nominator Information

Nominee Information

Full name of nominee*
Nominee location or country of origin*
Does the Nominee understand and speak English?*
Is the nominee a patient or caregiver?*
Has the nominee or the person they care for been diagnosed with chronic kidney disease or a rare kidney disease?*
If you selected rare kidney disease, please select which one.

For patient nominees: is the patient currently on dialysis?*
For patient nominees: did the patient receive a late stage diagnosis?*