COVID-19 Member of Congress Report Form
First Name
Your answer
Member of Congress State/Territory
Member's Name
Your answer
Date of Meeting
MM
/
DD
/
YYYY
Type of Meeting
Who attended the meeting?
Your answer
Was the Member of Congress present?
Your answer
What key issues were discussed?
Your answer
Did you ask your Member of Congress to reach out to HHS Secretary Azar regarding the Provider Relief Fund allocation?
Did you ask your Member of Congress about supporting $77B for Community Health Centers?
What are the key takeaways from the meeting?
Your answer
Is any follow-up needed by NACHC staff?
Additional comments?
Your answer
Advocate Name
Your answer
Advocate Title
Your answer
Advocate's Organization Name
Your answer
Advocate's Organization Type
Advocate's Email
Your answer
Advocate's Phone Number
Your answer
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