ADA SCID Roundtable Preliminary Questionnaire


First Name:
Last Name
Are you the person who will attend the ADA SCID Roundtable?
If you answered "No" above who will be participating?
Are you the ADA SCID patient
If you are not the patient, what is your relationship to the patient and what is the patient's name. (Use multiple lines if you are representing more than 1 patient.)
Your Email Address:
Do you have a PayPal account which we can use to send you your compensation for participation in the ADA Roundtable? Yes
No
If yes, please provide your PayPal Me link or the correct email address linked to your PayPal account.
What is your mailing address?
If you are the patient, what is your current age? If you are not the patient, what is the patient's current age?
Has anyone else in your immediate or extended family been diagnosed with ADA SCID?
If yes, what is that person's relationship to you and are they still alive?
Has anyone else in your immediate or extended family been diagnosed with another immune deficiency?
If yes: * what is their relationship to you? * are they still alive? * what was their diagnosis? (unknown if you do not know)
Do you feel that you are knowledgeable in the use of online conferences such as Zoom?
Would you like additional help or practice using Zoom?