JIA Autoinjector Feedback Study
Thank you for your interest, please answer the questions below so we can see if this is the right gig for you and, if so, we will follow up with additional details.
Name
*
First
Last
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Phone number
*
Are you the parent or legal guardian of a child between the ages of 12 and 17, who has been diagnosed with any of the following diseases? (If a different form of JIA, write in "other")
*
Polyarticular juvenile idiopathic arthritis (pJIA)
Systemic juvenile idiopathic arthritis (sJIA)
Juvenile sclerosis or scleroderma (jSSc)
Other
What is the age of your child?
Does your child suffer from hand impairment?
*
Yes
No
How long ago were they diagnosed with the condition above?
*
More than 1 month ago
Less than 1 month ago
Has your child or teen ever administered an injection to themselves, another individual or animal in the past 10 years?
*
Yes
No
Has your child or teen had a finger or thumb amputated?
*
Yes
No
Are you currently a resident of the United States?
*
Yes
No
Are you or your child "needle phobic" or would the proximity of a needle cause you or them significant distress or anxiety?
*
Yes
No
Submit
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