RESULTS Grassroots Media Report Form
Congratulations on your media success! Please let us know all about it by filling out this form for each RESULTS U.S. or global poverty media piece you or your RESULTS group generated. If your letter was printed in more than one paper, please fill out the form separately for each paper.

Remember to leverage your media by sending a copy to your congressional offices. Also, your media is a great way to engage others - use your example to invite people you know to submit their own media. Finally, share your success with your fellow RESULTS volunteers by posting it on the RESULTS Listserv and/or RESULTS Volunteers Facebook page. Learn more about leveraging your media at:

Contact Jos Linn at if you have any questions.
Sign in to Google to save your progress. Learn more
Email *
What is the name of the author or generator of the piece? *
What kind of advocate is the author/generator of the piece? *
Please choose the RESULTS group the author is a member of. If the author is from Dining for Women and not a member of a RESULTS group, please choose Free Agents (global or domestic) at the bottom of the list. *
If you chose "FREE AGENTS", "RESULTS FELLOWSHIP", or "OTHER" in the previous question, please provide the city and state where the author is located.
What type of media did you get published or broadcast? *
Date of publication/broadcast *
Name of media outlet *
In what state is the media outlet located?
Title of piece *
Which issues are covered in the piece (check all that apply)? *
Please provide an online link to the piece, if available *
What is the name of the person filling out this report? *
Who are your group's Regional Coordinators? *
Who did you send this media piece to in order to leverage it's impact (i.e., member(s) of Congress, Action Network)? *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy