Peer Support Volunteer Application (for non-neutropenic support person such as parent, spouse, sibling) CONTACT INFORMATION FOR VOLUNTEER Name Age and Gender Street Address City, Sate, Zip Code Home/cell number - please specify type Email Address Relationship to person with neutropenia INFORMATION ABOUT PERSON WITH NEUTROPENIA Name Age and Gender Type of Neutropenia Age at Diagnosis Member of the SCNIR (Severe Chronic Neutropenia International Registry)? If yes, when did they join? Neupogen/gcsf injections? If yes include dose and frequency of use. Bone pain? Bone Marrow aspiration? Biopsy? If yes, how often? Give brief history of infections. Hospitalizations? If yes, briefly summarize. Periodontal issues, gingivitis, mouth ulcers, other dental problems? If yes, briefly explain. Do you know the genetic origin of neutropenia? If so, please note which mutation. Have you been told to consider a bone marrow transplant for patient? FOR PARENTS---EXPERIENCE WITH NEUTROPENIA/HOW IT'S IMPACTED YOUR LIFE How do you and your child explain neutropenia to others? What activities do you allow you child to participate in? In person schooling Sports Outdoor play Sleep-overs Swimming Lake activities Ocean activities Other Are there activities you do not allow your child to participate in? Do you take any special precautions to avoid infection? Any social issues your child has struggled with? Educational issues you see as a result of neutropenia? How do you cope with stress as a result of neutropenia in your life? FOR SPOUSES AND PARTNERS--EXPERIENCE WITH NEUTROPENIA/HOW IT'S IMPACTED YOUR LIFE Has neutropenia impacted the quality of your relationship/marriage? How do you cope with stress of life with a partner who has a chronic illness? ADDITIONAL INFORMATION Why do you want to become a Peer Support Volunteer? Are there any subject areas you feel particularly qualified to discuss with a support seeker? Are there any subject areas you would prefer NOT to discuss with a support seeker? Do you fluently speak another language aside from English?Would you be comfortable being paired with a support seeker who speaks this other language? Do you have experience with private health insurance or disability insurance to help cover medical/neutropenia related expenses?Please specify. Are there any other issues/experiences that might be relevant to your participation as a Peer Support Volunteer? Thank you for you interest in becoming a Peer Support Volunteer for the National Neutropenia Network.By submitting this application and typed signature below, I affirm my interest in helping others seeking support for themselves or a loved one dealing with neutropenia. I acknowledge that I have willingly provided this information and that the National Neutropenia Network will not use it for any purpose other than to make the best matches between peer support volunteers and support seekers. I understand that once my application has been submitted, the NNN will review it and be in contact re: acceptance into the program. If accepted, the NNN will provide a training manual for review and then arrange for a 1:1 detailed review of the program. I agree to respond to support seeker inquiries in a timely manner (48 hours). If circumstances do not permit me to respond in a timely manner, I will contact an NNN representative to ensure the person seeking help gets timely assistance.
