Pediatric Vasculitis Patient Questionnaire

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* 1. Parent Name:

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* 2. What form of vasculitis has your child been diagnosed with?

Behçet’s syndrome

Eosinophilic granulomatosis with polyangiitis (EGPA)

Granulomatosis with polyangiitis (GPA)

IgA vasculitis (formerly Henoch-Schönlein purpura)

Kawasaki disease

Microscopic polyangiitis (MPA)

Polyarteritis nodosa

Takayasu arteritis (TAK)

Other

Other (please specify)

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* 3. When was your child diagnosed? (month & year)

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* 4. What is your child's first name?

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* 5. What year was your child born?

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* 6. Please check all that apply to you:

In the past, myself or my child has participated in a clinical trial.

I have never partcipated in a clinical trial, but have a general understanding of what's involved and why they are important.

In the past, I have participated in industry-led patient insight interviews or focus groups.

I am a healthcare professional (ie: medical assistant, nurse, physician).

None of the above

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* 7. Do you reside in the US?

Yes

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* 8. If you reside in the US, please list your city/state.

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* 9. If you do not reside in the US, please list your city/province & country.

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* 10. Would you be interested in sharing your child's experience living with vasculitis? Please select all that apply.

(industry may include pharmaceutical companies doing research in vasculitis, market research companies looking to understand the vasculitis patient journey, or another patient advocacy group collaborating with the VF)

Focus Group or Advisory Council (if VF-led)

Focus Group or Advisory Council (if industry-led)

Sharing your family's story to be used for social media via blog story or video (if VF-led)

Sharing your family's story to be used for social media via blog story or video (if industry-led)

Sharing your family's story at an in-person event (if VF-led)

Sharing your family's story at an in-person event (if industry-led)

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* 11. If you selected an industry-led selection above, do you grant the VF permission to share your contact information should they seek to connect with parents of pediatrics patients living with vasculitis?

Pediatric Vasculitis Patient Questionnaire

Question Title

* 1. Parent Name:

Question Title

* 2. What form of vasculitis has your child been diagnosed with?

Question Title

* 3. When was your child diagnosed? (month & year)

Question Title

* 4. What is your child's first name?

Question Title

* 5. What year was your child born?

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* 6. Please check all that apply to you:

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* 7. Do you reside in the US?

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* 8. If you reside in the US, please list your city/state.

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* 9. If you do not reside in the US, please list your city/province & country.

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* 11. If you selected an industry-led selection above, do you grant the VF permission to share your contact information should they seek to connect with parents of pediatrics patients living with vasculitis?

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* 12. Phone Number:

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* 13. Email Address: