U.S. House NIH Letter Feedback Form
The purpose of this form is to track which representatives were contacted, and what their responses were to our patient advocates and allies.
What is your name?
Your answer
What is your email address?
Your answer
In which state do you reside?
Your answer
What is your zip code (plus four). If you are unsure, click here: https://tools.usps.com/go/ZipLookupAction_input
Your answer
In which Congressional district do you reside?
Your answer
What is the name of your U.S. House representative?
Your answer
When did you make the initial contact with your representative's office?
Your answer
What was the name of the staff member with whom you spoke? (if applicable)
Your answer
What is the position of the individual with whom you spoke? (if applicable)
Your answer
What is the email address/contact information for the staff member (if applicable)?
Your answer
How did you contact this office?
How often did you contact this office?
Your answer
Did the office agree to sign the letter?
What was the office's general response? Was it positive? Negative?
Your answer
Is there anything else we should know about this particular representative and your interaction with the office?
Your answer
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