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1. KDAE Week Evaluation Form

ANNA wants to know about your Dialysis Unit Tour. Please fill out this survey to help us better serve you! ANNA Federal Health Policy Associates will follow up with the Congressional office with any additional information and reinforce the message(s) you delivered.

Thank you!

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* 1. Personal Information:

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* 2. Scheduled Visit Information

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* 3. List the names of any Staff members from the Member’s office who were present for the tour:

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* 4. List the names of other ANNA Members present for the tour:

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* 5. Does the Senator/Representative or staff have any personal connection to nursing or kidney disease (i.e. family member or friend with kidney disease or who is a nurse)? Please explain.

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* 6. Please list your Advocacy Action Item #1

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* 7. Did the Senator/Representative or staffer agree with Advocacy Action Item #1

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* 8. Please list your Advocacy Action Item #2

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* 9. Did the Senator/Representative or staffer agree with Advocacy Item #2

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* 10. Please list your Advocacy Action Item #3

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* 11. Did the Senator/Representative or staffer agree with Advocacy Action Item #3

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* 12. Describe any Concerns/Questions raised by Member/Staff:

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* 13. Describe any follow-up required with this office – (Things you promised or that ANNA needs to provide):

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* 14. Did you feel adequately prepared for the event by ANNA and the planning materials that were provided?

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* 15. Additional Comments:
Please include any additional information about what was discussed in this meeting and any other thoughts regarding follow-up from your meeting.

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