Kids and Injections Help iCAN by Sharing Your Feelings About Injections This questionnaire will be used by iCAN to better understand youth perception of injections (including subcutaneous and intramuscular injections). The goal for this information is to create a gold standard for manufacturers and regulatory bodies worldwide to consider when developing injectable drugs for pediatric health care. OK Question Title * 1. How do you feel about injections? Love them. No big deal. Hate them. OK Question Title * 2. Do you have a diagnosed condition that requires injections? Yes No OK Question Title * 3. For your diagnosed condition(s), how many of your prescribed medicine(s) are required to be injected? One Two Three Four Five Six or more Other (please specify) OK Question Title * 4. If you have an injection, do you prefer an Auto-Injector or a Syringe to be used? Auto- Injector Syringe I do not have a preference Other (please explain) OK Question Title * 5. Are you currently wearing a medical device that requires an injection using a needle threaded cannula or a sensor wire? Yes No OK Question Title * 6. How often is your medical device needle- threaded cannula or wire sensor inserted into your skin? Daily Every 1-3 days Every 4-6 days Weekly Every 10 days Monthly Other (please specify) OK Question Title * 7. How much of an advance warning do you like to have before receiving an injection? I like to know at least 30 minutes before. I like to know a day before. I like to know before scheduling my next appointment. I do not need to know in advance. Other (please specify) OK Question Title * 8. Are there techniques that you like to use to help relieve pain symptoms associated with an injection? Choose all that apply. Oral pain reliever Topical pain reliever (numbing cream) Buzzy (vibration device) Magic Spoon (cold metal spoon) Ice Pack Headphones with music Holding hands with a caregiver Countdown by nurse or caregiver Hugs with caregiver Nothing Other (please specify what you prefer) OK Question Title * 9. Do you have a preference for where you would like your injection to be given? Choose all that apply. Back of Arm Front of Arm Upper Buttock Lower Buttock Flank (lower back) Outer Thigh Top Thigh Stomach My condition/medicine determines the placement of my injection (Please specify location). OK Question Title * 10. Are there any areas on your body that you do not prefer to have injections? Please share and explain why (embarrassing, hurts, can't reach). Yes No Other (please specify) OK Question Title * 11. Are you able to measure and draw up your own medicine into a syringe or Auto-Injector? Yes No Other (please specify) OK Question Title * 12. Are you able to inject a needle into your skin independently of a caregiver? Yes No Other (please specify) OK Question Title * 13. If you do not give yourself injections, which of these caregivers do? Please select all that apply. Parent/Grandparent/Guardian Doctor Clinic/Hospital Nurse School Nurse Coach Sibling/Friend Other Person (please specify) OK Question Title * 14. Are you injections administered at home or away from home? Home Away from home Both home and away from home OK Question Title * 15. Please select all options that make it difficult to administer injections. Add any locations that are not listed. After school activities Sporting events Meals away from home Sleepovers At work When other people are around Vacation Travel Other locations (please specify) OK Question Title * 16. How frequently do you need injections? Multiple daily injections Daily injections Weekly injections Monthly injections Only need injections for vaccinations like flu shot Other (please specify) OK Question Title * 17. Do you have difficulty in remembering when you need an injection? Yes No Other (Please explain) OK Question Title * 18. How is the medicine used for your injections stored? (If you use more than one injected medicine, please fill out 'other' with storage needs). Refrigerated Room Temperature I don't know Other (please specify) OK Question Title * 19. When your medicine is injected, is there less pain if the medicine is stored at room temperature? Yes No I don't know I can't store my medicine at room temperature Other (please specify) OK Question Title * 20. Do side effects to your injected medicine impact your desire to have future injections? Yes No Other (please specify) OK Question Title * 21. Do you have to keep your injected medicine with you at all times? Yes No Other (please specify) OK Question Title * 22. Please share how you store your injected medicine when you are traveling. OK Question Title * 23. Please share how you dispose of your syringe needles or Auto-Injector. OK Question Title * 24. Is there anything you would like us to know about kids and injections? OK Question Title * 25. What is your age? 8 9 10 11 12 13 14 15 16 17 18 19 20-25 26-30 30 + OK Question Title * 26. Are you a member of an iCAN Chapter? Albania Barcelona Bari Canada Central Ohio Childhood Cancer Connecticut DRC Florida Florida Tech / Scott Center / KIDS United France Georgia Germany Gen R Hope for Henry/ Children's National Houston Illinois Kansas City Los Angeles Madrid Michigan Moorefields Eye Netherlands Rome ScotCRN Tokyo Uganda UP (UP Michigan) Virtual I am not part of a chapter (please specify home state/country and contact Amy Ohmer at firstname.lastname@example.org to be added) OK THANK YOU!