Survey - An Act Establishing Emergency Medical Services for Veterans H.2765
We are seeking information from Veterans and their family members about their experiences with Emergency Medical Services. The results of this survey will be included in the public hearing on the bill in spring 2017, using only non-identifying information. Your input is important and will assist in documenting the need for An Act Establishing Emergency Medical Service for Veterans H.2765. For more information please visit www.donaldjarvis.com
Email address *
Survey Questions
Are you a United States Veteran? *
Are you currently enrolled in VA Services? *
Are you a resident of Massachusetts? *
What is your age group? *
What is your gender? *
Have you utilized Emergency Room services at any of the following: *
Required
Testimonial
Type your testimonial here: *
Please share your personal statement in support of Bill H.2765 and its importance to Veterans of Massachusetts. You can include information such as: your personal experiences with Emergency room visits, Emergency visit medical bills and whether the VA paid the bills or any other personal experiences you wish to share regarding Emergency Services for Veterans.
Your answer
Do you authorize the use of the information you have provided as part of the supporting documentation presented during the public hearing at the State House in support of Bill H.2765. Testimonials will be presented using only non-identifying information. *
Are you interested in attending the Public Hearing at the Massachusetts State House in Boston? *
Join Our Mailing List
Join our Mailing List?
Enter your E-mail address below to be included in our mailing list.
Your answer
Thank you!
We appreciate your time and effort in sharing your experiences and your support of bill H.2765.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service