GPA & MPA Patient Questionnaire Question Title * 1. Name: Question Title * 2. Please indicate the age range you fall into. 18-30 31-40 41-50 51-60 61 and older Question Title * 3. Do you reside in the US? Yes No Question Title * 4. Which state do you reside in? Question Title * 5. If you do not live in the US, please list which country you reside in? Question Title * 6. Have you been diagnosed with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)? Yes No Question Title * 7. When were you diagnosed? (month and year) Question Title * 8. Have you experienced any kidney-related issues or symptoms as a result of your vasculitis? Yes No Question Title * 9. If you've experienced any kidney-related issues or symptoms, when did that begin? My kidneys were involved from the beginning of initial vasculitis symptoms I developed kidney-related symptoms as the vasculitis progressed Not Applicable Question Title * 10. Would you be interested in sharing your experience living with GPA or MPA? Please select all that applies: Focus Group or Advisory Council (if VF-led) Focus Group or Advisory Council (if industry-led) Sharing your story to be used for social media via blog story or video (if VF-led) Sharing your story to be used for social media via blog story or video (if industry-led) Sharing your story at an in-person event (if VF-led) Sharing your story at an in-person event (if industry-led) None of the above Question Title * 11. If you selected an industry-led selection above, do you grant the VF permission to share your contact information should they seek to connect with patients living with GPA or MPA? Yes No Not Applicable Question Title * 12. Contact Information: Country CodePhone numberAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFederated States of MicronesiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French Part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Question Title * 13. Contact Information: Email address Thank You!
