My Dialysis Plan 2021-2026 Tracking and Online Reporting Instructions

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*1.	Select your dialysis facility:

*2.

Person completing this report:

First Name
Last Name
Email Address

3.	Please enter your question(s) related to the content you just viewed. The Network staff will review all submitted questions and post a Q/A document with response to all questions.

	Remaining characters: 4000

4.

Overall how would you rate the content you just viewed?

5.	Share at least one take away, action item you identified from the video, or your overall feedback:

	Remaining characters: 500

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