Exit this survey 2014 Congressional Feedback Form Share your feedback with us following your meetings with members of Congress. This information is valuable in providing follow-up communication to congressional offices and maximizes our advocacy efforts on behalf of physicians. Question Title * 1. Please tell us about yourself: Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Email Address: Phone Number: Please tell us about the office you visited. You will have the opportunity to tell us about your other hill/district visits on subsequent pages. Question Title * 2. Who did you meet with? (check all that apply) Senator/Representative Staff member(s) Name of person(s) you meet with Question Title * 3. Your relationship with this individual? (check all that apply) First time visiting Constituent Personal friend or relative Financial donor Acquaintance Campaign adviser or volunteer Other (please specify) Question Title * 4. Did you ask your legislator to enact legislation this year that promotes new delivery and payment models and repeals the SGR and, if so, what was your legislator’s response? Question Title * 5. Is your legislator willing to take additional action to move this issue forward by signing a letter of support, contacting House and Senate leadership to urge them to make SGR repeal a priority in 2014, etc.? Briefly explain: Question Title * 6. Which statement best describes the legislator’s position and sense of urgency for repealing the SGR and enacting legislation that promotes new delivery and payment models? (please choose one) Believes there is a real sense of urgency on the part of leadership in Congress to finally repeal the SGR and enact payment and delivery reform; reasonably confident this will be done before the end of the year to avoid the threat of another short term SGR patch or payment cuts. Believes there is a real sense of urgency on the part of leadership in Congress to finally repeal the SGR and enact payment and delivery reform; reasonably confident this will be done before the end of Understands the need to resolve this issue, but has concerns other priorities will push full SGR repeal as well as payment and delivery reform off until at least 2015 -- resulting in another short term SGR patch at the end of the year.he year to avoid the threat of another short term SGR patch or payment cuts. Dismisses the urgency of the issue. Knows that Congress has consistently applied temporary patches and believes it will continue to do so. Comments: Question Title * 7. Additional comments about this hill visit or district meeting (please include any AMA follow up needed): Question Title * 8. Would you like to receive legislative updates and alerts from the AMA's Very Influential Physician grassroots program? Yes No Done
