Rolling-Bronchiectasis and NTM Care Center Network (CCN) Application Oct 2025

  • Bronchiectasis and NTM Care Center Network (CCN) Application

  • *For the best user experience, it is recommended to use the Google Chrome browser when completing the application.

  • If you would like to review the description and requirements for each Center type, you may do so by clicking the link below.

    Link to CCN Requirements

  • Please specify the type of Center for which you would like to be considered. Please note that the final designation will be determined after the application review and onboarding process (if accepted) has been completed. (Select One)*
  • Please select the application type that applies to this submission.*
  • Format: (000) 000-0000.
  • Proposed Center Director credentials/degree*
  • Does proposed Center Director have a biosketch prepared?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Proposed Center Director's specialty*
  • Do you have on-site (i.e., within institution) access to a Board-certified ID specialist for consultative clinical care?
  • Do you have access to a local, Board-certified ID specialist for consultative clinical care?
  • Do you have on-site (i.e., within institution) access to a Board-certified pulmonary specialist for consultative clinical care?
  • Do you have access to a local, Board-certified pulmonary specialist for consultative clinical care?
  • Is the proposed Center Director Board certified in the given specialty?*
  • Does the Center have a proposed Co-Director?*
  • Format: (000) 000-0000.
  • Proposed Center Co-Director Credentials/Degree
  • Does proposed Center Co-Director have a biosketch prepared?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Proposed Co-Center Director's specialty
  • Is the person filling out this application the Proposed Center Director?*
  • Is your Center a CF Care Center?*
  • Is your Center accredited and approved by CMS?*

  • 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.

  • Program Framework/Structure

  • Does your facility hold multidisciplinary meetings to review bronchiectasis and NTM patient cases, diagnostic procedures, treatment plans, etc.?*
  • How frequent are these meetings? Note that all designated CCN Care Centers will be required to hold multidisciplinary meetings.
  • What members of the clinical team attend your center's multidisciplinary meetings where case presentations are discussed? (Choose all that apply)
  • Does your center have operational meetings (ex: huddles, team meetings, staff meetings, pre-clinic meetings, etc.)?*
  • Who attends these meetings? (Choose all that apply)
  • What topics are discussed during team meetings? (Choose all that apply)
  • What is your centers average wait time for NON-URGENT appointments for patients with bronchiectasis and/or NTM lung disease to be seen at your center?*
  • What is your centers average wait time for URGENT appointments for patients with bronchiectasis and/or NTM lung disease to be seen at your center?*
  • Is there a direct line or electronic option for patients to reach bronchiectasis and/or NTM program?*
  • Does your center have an established telemedicine infrastructure to increase access to care for patients lacking proper transportation and/or patients who live beyond a reasonable distance from your center?*
  • Does your center make medical records available electronically?*
  • Rows
  • Rows
  • Does your center have a partnership with a local Veteran's Administration (VA) hospital?*
  • Does your center have a partnership with a public city/state hospital or healthcare center?*

  • 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.

  • Research and Publications

  • Does your Center have an established Clinical Research Program?*
  • Is you center currently involved in translational or basic science research?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Is your center currently involved in clinical trials?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Has your Center participated in any publications as they pertain to bronchiectasis and NTM lung disease over the past three years?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 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.

  • Diagnosis and Therapeutics

  • Does your Center have a standard protocol for the diagnosis and treatment of bronchiectasis?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does your center have a standard protocol for the diagnosis and treatment of NTM?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does your Center have on-site access to a CT scanner and chest radiologist for diagnosis/confirmation of bronchiectasis?*
  • Does your Center have on-site access to pulmonary function testing?*
  • Has your Center identified a local site to which patients can be referred for pulmonary function testing?
  • Does your Center have access to and refer patients to pulmonary rehab?*
  • Is there a pulmonary rehab facility at your institution?*
  • Where are your sputum samples processed?*
  • Where is sensitivity testing done?*
  • Does your site receive NTM speciation for MAC species?*
  • Does your site receive NTM speciation for non-MAC species?*
  • Does your site receive NTM sub speciation for M abscesses species?*
  • Does your Center have an established plan for the coordination of care, including a mechanism to deliver outpatient clinic reports and discharge summaries to referring and collaborating physicians?*
  • Does your Center have access to a specialty pharmacy?*
  • Does your Center have personnel to educate patients regarding medication and guide them through insurance claims and appeals?*

  • 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.

  • Clinicians, Personnel, and Staffing

  • Have you identified personnel who could fill the role of Center Coordinator upon admission to the program? (By hovering over this question with your mouse, you will be provided with a list of Care Center Coordinator's potential responsibilities.)*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • For the following health care services below, please indicate what is available for your patient visits. 

  • Respiratory Therapy (PFTs and 6-minute walk tests)*
  • Respiratory Therapy (patient education sessions)*
  • Respiratory Therapy (airway clearance/chest physiotherapy)*
  • Respiratory Therapy (pulmonary rehab)*
  • Social Worker*
  • Psychologist/Psychiatrist*
  • Pharmacist/Pharm D*
  • Lung Transplant Specialist*
  • Thoracic Surgeon*
  • ENT*
  • GI*
  • Speech/swallow therapy*
  • Nutritionist/Dietitian*
  • Rows

  • 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.

  • Staffing Education

  • 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

  • Are there any other bronchiectasis and NTM centers that you are working closely with to provide patient education or referrals for other resources?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Clear

  • To complete and submit form you must click "review" button below. Once answers are reviewed, please click "submit" at the bottom of the form to complete.

  • Should be Empty: