LEGISLATIVE FEEDBACK FORM

LET'S GET STARTED

Use a separate form for each legislative visit.

Question Title

* 1. NURSE COMPLETING THE FORM

Name:

Email Address:

Cell Number:

Question Title

* 2. INDIVIDUAL OR COMMITTEE CONTACTED

Question Title

* 3. SENATOR, REPRESENTATIVE OR COMMITTEE

SENATOR

REPRESENTATIVE

COMMITTEE

Question Title

* 4. DATE OF CONTACT

DATE

Date

Question Title

* 5. ISSUES DISCUSSED/COMMENTS - Include the degree of interest in and position taken on the issue.