Advocacy Feedback Form

Please use this form for each interaction with your Member(s) of Congress and/or legislative office. This information will help us to have a stronger voice with the CHD community. Thank you for taking action!

Question Title

* 1. Please provide your name:

Question Title

* 2. Today's Date

Please complete:

Date

Question Title

* 3. Member of Congress:

Question Title

* 4. State:

Question Title

* 5. Date action was taken:

Please complete:

Date

Question Title

* 6. How did you take action? (please select one)

Called Washington D.C. Office

Called District Office

Sent an email to contact in Washington D.C. Office

Visited the Washington D.C. Office

Visited the District Office

Attended a Town Hall Meeting

Referred to my legislator on Social Media

Other (please specify)

Question Title

* 7. Was the action in response to an Adult Congenital Heart Association Advocacy Alert?

Yes

Other (please specify)