Peer Support Volunteer Application (for person with neutropenia) CONTACT INFORMATION FOR PERSON WITH NEUTROPENIA Name Age and Gender Street Address City, State, Zip Code Home/cell number--please specify Email address Type of neutropenia Age at diagnosis Do you have children? Does your child(ren) have neutropenia? If you have congenital neutropenia, do you know the genetic origin? Please specify. Member of the SCNIR (Severe Chronic Neutropenia International Registry)? If yes, when did you join? Do you take Neupogen/gcsf injections? If yes, include dose, frequency, and duration of use. Do you have bone pain? If yes, how do you manage it? Do you have any other side effects that you attribute to Neupogen/gcsf? If yes, please explain. Have you had bone marrow aspirations? Biopsy? If yes, how often? Give a brief history of infections including hospitalizations. Do you experience gingivitis, mouth ulcers, other dental issues? If yes, please explain briefly. Do you experience fatigue? If yes, please describe how often, how you manage it, and how it impacts your life. Have you ever been told to consider a bone marrow transplant? Does your neutropenia inhibit you from participating in specific activities? Work/Job Fitness programs Travel Education Other Are you satisfied with the medical care you receive? Does your physician understand neutropenia? Do you take any special precautions to avoid infection? Do you have experience with private health insurance or disability insurance to help cover medical/neutropenia related expenses?Please specify. Has accessibility to health insurance been a challenge for you? How would you explain your neutropenia to others? 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? Are there any other issues/experiences that might be relevant to your participation as a Peer Support Volunteer? Thank you for your 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.
