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The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([0-9]{3})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

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Preliminary_Survey

Returning?

A A A

Dear HAE Patient and Members of Your Household,

The US HAEA Angioedema Center at UC San Diego and the US Hereditary Angioedema Association (HAEA) encourage you to participate in an important study on COVID-19 (coronavirus disease 2019). Please complete the survey whether or not you have been infected with the virus. The information you provide will help us understand whether the virus affects people with HAE differently than people who do not have HAE. We will share the findings with the HAEA and scientific communities when the study is concluded.

Participation in this study is voluntary and you may withdraw at any time. Your answers are anonymous, and you cannot be connected to the information you provide. Completing the questionnaire will take approximately 10 minutes.

To understand the risks posed by COVID-19 for people with HAE, we need to obtain information about everyone in your household. It is important that a survey be completed for every member of your household whether they have HAE or not. Individual household members can fill out their own survey or have someone else in the household complete a survey on their behalf. Any children in your household (less than 18 years of age) must have their survey completed by an adult.

If you have any questions you may contact either: Christine Selva at the US HAEA (cselva@haea.orga.org) or Dr. Tukisa Smith at UC San Diego (tusmith@health.ucsd.edu)

This is a research survey that is being undertaken by the US HAEA Angioedema Center at UCSD in collaboration with the US HAEA. It is entirely voluntary and anonymous. We are not collecting any information that will allow us to trace the answers back to you. You do not need to participate in this survey and you may stop participating at any time. Since the data is anonymous, we cannot remove your answers once you submit your responses.

Are you willing to participate in this project (either for yourself or another member of your household)?

* must provide value

Yes

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Do you have HAE?

* must provide value

Yes

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Every participant should complete an initial survey. If this is the first survey for yourself or the person you're filling this out for, click on the "New Person Survey" button.

If you already filled out the initial survey but got COVID-19 afterwards, we have a brief follow-up survey. If you are filling out a follow-up post-COVID-19 survey, please click on the "Follow-up Survey" button.

* must provide value

New Person Survey

Follow-up Survey

reset

This is a shortened survey for people who previously completed the questionnaire but have had COVID-19 SINCE finishing the initial survey.

If this does not apply in this case, then please change your answer above and select "New Person Survey"

If this is indeed the correct survey, enter the "Personal Followup Code" created when the initial survey was completed for yourself or the person you're filling this out for.

* must provide value

Do any people other than yourself live in your home?

* must provide value

Yes

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Please click on submit and you will be taken to the next section of the survey.

How many people other than yourself live in your home?

* must provide value

Ten or more

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Every household participating in this survey needs to designate 1 survey leader. Please discuss this within your household and pick a survey leader. Once she or he has been chosen, the survey leader needs to be the first person in that household to take the survey

Are you the survey leader for your household?

* must provide value

Yes

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Survey answers are completely anonymous, and we will not know who completes the surveys. To be able to group survey responses by household, we are asking you to create a special "Household Code". This can be any combination of letters, numbers, or symbols. Share this code with all the members of your household.

You should have been given a "Household Code" by the survey leader in your household. If not, please ask him or her to give you the "Household Code".

Please enter the "Household Code" below:

Is this survey about you?

* must provide value

Yes

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Please click on submit and you will be taken to the next part of the survey.

What is your relationship to the person who gave you the password?

Grandfather

Grandmother

Father

Mother

Uncle

Aunt

Brother

Sister

Cousin

Son

Daughter

Spouse

In-law

Non-related household member

Non-related caretaker

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Please click on submit and you will be taken to the next part of the survey.

What is your "Personal Followup Code"?

(Please make sure that you've completed your own survey before filling out a survey for another person. We are asking for your "Personal Followup Code" so that we can understand the relationships in your household. This does not jeopardize your anonymity.)

Who are you filling this out about?

Grandfather

Grandmother

Father

Mother

Uncle

Aunt

Brother

Sister

Cousin

Son

Daughter

Spouse

In-law

Non-related household member

Non-related caretaker

reset

Please click on submit and you will be taken to the next part of the survey.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.