NAPCRG Research Advocacy Contact Form

Thank you for contacting your legislator. Please answer the questions below and complete this form for each point of contact.

Question Title

* 1. Your Name:

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* 2. Date of Contact:

Date / Time

Date

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* 3. Method of Contact:

Phone

Letter

In-Person

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* 4. Your Legislator's Name:

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* 5. Did you communicate with a person at the office?

Yes

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* 6. With whom did you discuss your issues?

Name

Title

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* 7. Topics of Discussion (select all that apply):

AHRQ

PCORI

Moving AHRQ into the NIH

Primary Care Research (General)

Other (please specify)

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* 8. Response to the ask(s):

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* 9. Were there any outstanding questions?

Yes

If yes, please write them down here:

Question Title

* 10. If you would like assistance with answering these questions, please check this box, and someone from the NAPCRG Research Advocacy Committee or staff will contact you.

Check here if you would like someone to contact you.

Question Title

* 1. Your Name:

Question Title

* 2. Date of Contact:

Question Title

* 3. Method of Contact:

Question Title

* 4. Your Legislator's Name:

Question Title

* 5. Did you communicate with a person at the office?

Question Title

* 6. With whom did you discuss your issues?

Question Title

* 7. Topics of Discussion (select all that apply):

Question Title

* 8. Response to the ask(s):

Question Title

* 9. Were there any outstanding questions?

Question Title

* 10. If you would like assistance with answering these questions, please check this box, and someone from the NAPCRG Research Advocacy Committee or staff will contact you.

Question Title

* 11. Any other comments?