National Physicians Alliance Policy-Maker Meeting Report Form
Please use this form to tell us about discussions with your elected officials. If you have questions or need assistance please contact Becky Martin, NPA Advocacy Director, cell 941/518-7051 or email becky@npalliance.org
Email address
Your Info: (first & last name, degree)
Your answer
Your Specialty:
Your answer
Your Cell Phone:
Your answer
Senate/Representative Office Meeting/Call with:
Your answer
Issue/Focus of Meeting:
Your answer
Senate/Representative Office Meeting/Call date:
MM
/
DD
/
YYYY
DC Office Meeting
In-District Meeting
Call with DC Office
Call with In-District Office
Meeting/Call Type
Meeting/Call with & contact info (first & last name, title, email, phone):
Your answer
Questions Asked on Issue by Staff or Congress Member:
Your answer
Position Taken on Issue During Meeting?
Your answer
Meeting/Call follow-up?
Your answer
Comments:
Your answer
A copy of your responses will be emailed to the address you provided.
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