NW3 Video Attestation - Life Plan
Create
Facility Information
Select your state/Territory/District:
Select your facility
State/Territory:
Dialysis Facility CCN (6 digit CMS Certification Number):
Title / Role at Facility
Other Role:
Contact Information
Facility Contact First Name
Facility Contact Last Name
Facility Contact Email
Preferred Language
Preferred Language:
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.
No PHI / PII in the following fields.
Examples of PHI include patient name or initials, birthdate, SSN, etc.
Next Step: Video
Previous Page
Next Step: Questions
Previous Page
Questions
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.
Overall how would you rate the content you just viewed? Scale: 5 - Excellent, 4 - Good, 3 - Satisfactory, 2 - Needs Improvement, 1 - Poor
Share at least one take away, action item you identified from the video?
What additional learning modules/topics would you like to see presented in this format?
Next Step: Verify and Submit
Previous Page
Verify you are not a robot and submit your data using the Submit button
at bottom of the form
Submit Data
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.