Bronchiectasis and NTM Care Center Network (CCN) Application 2025

	Percentage of Patients
White
Black or African American
Asian
Hispanic
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Other
None/Unknown

	Percentage of Patients
Commercial Insurance
Tricare
Medicaid or other state-promoted program
Medicare
No Insurance
Other
Unknown

Research and Publications
Does your Center have an established Clinical Research Program?*

YesNo
Provide the details of your Clinical Research Program including the involvement of the Center Director/Co-Director, if applicable.
Is you center currently involved in translational or basic science research?*

YesNo
Upload a list of current translational, and basic studies that relate to bronchiectasis and NTM lung disease that your Center is conducting. (You may include NCT or short titles.)

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Is your center currently involved in clinical trials?*

YesNo
Upload a list of current bronchiectasis and/or NTM research studies including grants, and multi-centered trials that your Center is conducting. (You may include NCT or short titles.)

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Has your Center participated in any publications as they pertain to bronchiectasis and NTM lung disease over the past three years?*

YesNo
Upload a list of your Center's publications as they pertain to bronchiectasis and NTM lung disease over the past three years; please limit to 10 publications.

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Staffing Education
Provide evidence of ongoing participation in continuing medical education and professional practice improvement of the Center Director.*
Recommendation: The Center Director needs to show evidence of ongoing participation in continuing medical education relevant to the treatment and management of those with bronchiectasis and NTM lung disease. (Examples can include recent professional practice improvement or evidence-based updates to clinical practice)
Provide evidence of ongoing participation in continuing medical education and professional practice improvement of the Co-Director.*
Recommendation: The Center Director needs to show evidence of ongoing participation in continuing medical education relevant to the treatment and management of those with bronchiectasis and NTM lung disease. (Examples can include recent professional practice improvement or evidence-based updates to clinical practice)
Please provide details of any efforts planned to ensure continuing medical education for core staff (e.g., Advanced Practice Providers, RTs, RNs, Nutritionists, etc.)*
To save and return to form at a later time, click "save". If you already have a jot form account, an email will be sent to you containing a link that will allow you to continue completing the form where you left off. If you do not already have a jot form account, you will be prompted to create an account. Once an account is created, you will then receive the email with your form and its saved progress.

Community and Patient Education
Provide specifics of your current approach to educating and providing support to patients and caregivers about bronchiectasis and NTM lung disease. *
Are there any other bronchiectasis and NTM centers that you are working closely with to provide patient education or referrals for other resources?*

YesNo
List the center(s) and explain the relationship involved.
Provide details of initiatives that your clinic has implemented to address patients’ needs regarding health care disparities/inequities, such as bias training of healthcare providers, community resources, patient transportation concerns, translations, and/or lack of access to health care and pharmacologic therapies.*
Please write 3-5 sentences explaining your interest in joining the Care Center Network.*
Please include any information here to clarify your answers to the above questions or that would be pertinent to the consideration of your application.
Additional Uploads:

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I verify that all information provided in this application is true to the best of my knowledge. Please type your name below. *

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Should be Empty:

	Number of Staff	Total Percent Effort
Center Director
Nurse Practitioner
Physician Assistant
Nutritionist/Dietitian
Respiratory Therapist
Clinical Coordinator
Social Worker
Behavioral Psychologist
Pharmacist/Pharm D
Pulmonologist (if not Center Director)
Infectious Disease (if not Center Director)
Additional Pulmonologist
Additional Infectious Disease
Other

Bronchiectasis and NTM Care Center Network (CCN) Application