Military Questionnaire

NAF is making a special outreach to community members who either served in the US military or have a family member (spouse, parent, child, sibling, grandparent) who served. NAF is exploring a research program run by the Department of Defense and the possibility of adding Ataxia. It will be helpful to show a connection between military families and Ataxia. Thank you for helping NAF with this project by sharing your family's experiences.

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* 1. Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Who in your family served in the military?

Myself

Spouse

Child

Parent

Sibling

Grandparent

Other (please specify)

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* 3. What Branch(es)

Army

Navy

Marines

Coast Guard

Air Force

Space Force

National Guard/Reserves

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* 4. Who in your family has Ataxia?

Myself

Spouse

Child

Parent

Sibling

Grandparent

Other (please specify)

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* 5. Have you or your family used the VA medical system for diagnosis or treatment of Ataxia?

Yes

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* 6. Would you be willing to meet with or contact you Member of Congress about this initiative? If necessary, NAF would follow up with you regarding the details.

Yes