LEGISLATIVE REPORTING FORM
Please use this form to report activity with your legislator. Please fill out one form for every meeting.

For any questions regarding grassroots, please contact the Grassroots co-chairs:
Linda Medeski, OD drlinda@mednicpc.com
Jennifer Crown, OD jenncrown@yahoo.com
Stacy Tovarek, OD stovarek@gmail.com

Date of Meeting *
MM
/
DD
/
YYYY
District *
Your answer
Legislator: *
Required
Legislator Party *
Name of Legislator *
Your answer
Name & contact of Doctors attending (your name). Please include ALL people that attended *
Your answer
Nature of meeting/event (campaign help, personal meeting, town hall, etc) *
Your answer
Subjects Discussed (Did legislator know you were there? What was level of contact?) *
Your answer
Comments by Legislator:
Your answer
What Information Did You Leave With Your Legislator? *
Your answer
Does Someone From OPW Need to Contact This Legislator? If so, please explain. *
Your answer
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