VAFP Key Contact Survey - Make the Voice of Family Medicine Heard!

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* 1. Please enter your contact information below.

First Name

Last Name

Suffix (MD, DO, FAAFP, etc.)

Practice/Institution Name

Home Address

Home City

Work Address

Work City

E-mail

Phone

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* 2. How well do you know your home/workplace's district Delegate or Senator?

Not at all

Know by name only

Have had occasional direct contact with my Delegate or Senator

I am in regular contact with my Delegate or Senator

My Delegate or Senator is a patient of mine

Other (please specify)

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* 3. Please list any legislators with whom you presently have a relationship.

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* 4. Would you like to be a key point of contact for your legislator on family medicine issues?

Yes

No

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* 5. Do you have any additional comments regarding the Key Contact Program or the VAFP's Political Action Committee FamDocPAC?