Lobby Report Form Question Title * 1. Pre or Post Visit Report? Meeting Scheduled (complete questions 1-6) Meeting Completed Question Title * 2. Date of Visit Question Title * 3. Point Person / Anchor Question Title * 4. Phone Number Question Title * 5. Email Question Title * 6. Name of Legislator Visited (will visit) Question Title * 7. If not the Legislator, who on their staff did you meet with? Please provide their name and title Question Title * 8. Who else attended the visit with you? Please provide full namesIf more than 5 attended, add multiple names in each box as needed 1 2 3 4 5 Question Title * 9. What issues did you discuss in the visit?Check all that apply Safe Staffing in Hospitals and Nursing Homes Long Term Care Regulations Hospital Safe Patient Limit Bills Fair Funding Other (please specify) Question Title * 10. Rate how well you feel the visit went: Terrible Average Excellent Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 11. Rate how supportive the Legislator is of our issue: Actively Against Neutral Actively For Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 12. What did the Legislator agree to do? Check all that apply Vote the Way We Want Co-Sponsor Be a Champion for Us on This Issue Host a Public Hearing / Townhall / Forum Encourage Other Decision-Makers to Take Action Other (please specify) Question Title * 13. What personal stories did you tell? Question Title * 14. What follow up would you suggest with this Legislator? Submit