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What Keeps You Up at Night?
1.
Demographics
*
1.
What year was the patient born? (YYYY). (If you are a care partner completing this survey, please enter the patient's birth year.)
(Required.)
*
2.
What is your relationship to vasculitis?
(Required.)
Patient
Parent of patient
Family/friend of patient
Health Care Professional
Researcher
Corporate Partner/Sponsor
Other (please specify)
*
3.
What is the patient's race or ethnicity?
(Required.)
White or Caucasian
Black or African American
Hispanic or Latinx
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Prefer not to answer
Other (please specify)
*
4.
What is the patient's gender identity?
(Required.)
Male
Female
Gender non-binary
Transgender
Transgender, male to female
Transgender, female to male
Prefer not to say
*
5.
What type of area does the patient live in?
(Required.)
Rural area
Small town or city (<100,000 residents)
Medium city (100,000-500,000 residents)
Large city (>500,000 residents)
*
6.
What was the total household income (USD) in 2024, before taxes?
(Required.)
Less than $50,000
$50,000 - $100,000
$100,001 - $250,000
$250,001 - $500,000
Over $500,000
Prefer not to answer
