230704 ANCA screener
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
1. Do you have ANCA associated vasculitis?
*
Yes
No
2. If yes, do you know if you are diagnosed with Granulomatosis with polyangiitis (GPA), Microscopic Polyangiitis (MPA), or other form of ANCA associated vasculitis?
*
Yes, I am currently diagnosed with GPA
Yes, I am currently diagnosed with MPA
I am currently diagnosed with other type of ANCA associated vasculitis (such as EGPA)
I am diagnosed with ANCA associated vasculitis but I am not sure if it is MPA or GPA
3. How old are you?
*
4. Have you been informed by your clinician that you have renal complications, or low Estimated Glomerular Filtration Rate (eGFR) levels?
*
Yes
No
I don’t know
5. Do you happen to know the results of your last eGFR blood test?
*
Yes
No
5a. If you responded yes to the previous question please note here your eGFR level and the date of the test:
6. Are you physically able to participate in a one-on-one, 60-minute telephone interview (conducted in one sitting) in English using an internet-enabled computer or other device with screensharing / screen-viewing capabilities?
*
Yes
No
7. Will you be able to understand and speak in English during the interview?
*
Yes
No
8. Are you able to provide documentation from your doctor or from your medical records (for example patient portal) that confirm your ANCA associated vasculitis and the subtype?
*
Yes
No
Not sure
9. Do you have any other disease along with ANCA associated vasculitis (AAV) which might have similar symptoms as those of AAV? For example: systemic lupus erythematosus (SLE), IgA vasculitis (Henoch-Schönlein), rheumatoid vasculitis, Sjögren's syndrome, anti-glomerular basement membrane disease, or cryoglobulinemic vasculitis
*
Yes
No
Not sure
10. Will you have access to an internet browser and a computer/electronic screen during the interview?
*
Yes
No
11. What is your gender?
*
Female
Male
Non-binary / non-conforming
Prefer not to say
12. What is your race?
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Other
13. What is your ethnicity?
*
Hispanic or Latino/a
Not Hispanic or Latino/a
Prefer not to say
14. What is your employment status?
*
Working full-time
Working part-time
Seeking work opportunities
Student
Retired
Unable to work
Homemaker
Prefer not to say
Other
15. What is your education level? Select only one option.
*
Less than high school
High school graduate or GED equivalent
Some college
Bachelor’s degree
Graduate degree
Prefer not to say
Other
16. If there is anything relevant you would like to add about your condition or make us aware of, feel free to do so here (optional):
Submit
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