SURVEY
Thank you for taking part in this survey. Please answer the following 1. What is your Gender? (Circle one)
Female Male
2. Age: ________years
3. Please specify your ethnicity. (Circle one) Black or African American
White
Hispanic or Latino
Native American or American Indian Asian / Pacific Islander
Other
4. What is the highest level of education you’ve completed? (Circle one) Some high school [9-11 years] or less
Graduated high school/GED
Graduated college (Bachelor’s Degree)
Completed Graduate Studies (Master’s or Doctorate Degree)
5. What insurance do you use to pay for your healthcare? Check all that apply, indicate if it is primary, secondary
Primary? Secondary?
Public Aid/Medicaid State Renal Program Medicare
Private insurance None
Please answer the following questions based on your personal experience. There are no right or wrong answers. Please circle your response.
1. I forget to take my medication
Always Often Sometimes Rarely Never 2. I take a different dosage of my medication than my doctor prescribes
Always Often Sometimes Rarely Never 3. I stop taking my medication for a while
Always Often Sometimes Rarely Never 4. I decide to skip one of my medication dosages
Always Often Sometimes Rarely Never 5. I use my medication less than is prescribed
Always Often Sometimes Rarely Never
Please answer the following questions based on your personal experience when receiving treatment for your kidney disease. Please think about your interactions at your dialysis clinic, during other doctor’s visits and hospital visits outside of your dialysis clinic. There are no right or wrong answers. Please circle your response. When receiving treatment for your kidney disease:
1. You are treated with less courtesy than other people.
Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely, what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation
2. You are treated with less respect than other people.
Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely, what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation
j. Your Education or Income Level
3. You receive poorer service than others.
Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation
4. A doctor or nurse acts as if he or she thinks you are not smart.
Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely, what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation
j. Your Education or Income Level
5. A doctor or nurse acts as if he or she is afraid of you.
Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely, what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation
6. A doctor or nurse acts as if he or she is better than you.
Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely, what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation
j. Your Education or Income Level
7. You feel like a doctor or nurse is not listening to what you were saying. Always Most of the Time Sometimes Rarely Never
If you answered Always, Most of the Time, Sometimes, or Rarely, what do you think was the main reason for this experience? Please circle your response:
a. Your Ancestry or National Origins b. Your Gender c. Your Race d. Your Age e. Your Religion f. Your Height g. Your Weight
h. Some other Aspect of Your Physical Appearance i. Your Sexual Orientation