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TSC MOTH Feedback

TSC Alliance March on Capitol Hill Appointment Feedback

Appointment Information

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Appointment Record

Your Name(Required)

First Last

Your Email(Required)

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Your Cell Phone Number

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Appointment Date

MM slash DD slash YYYY

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Appointment Time

Hours

:

Minutes

AM/PM

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Appointment Time Zone

EST

CST

MST

PST

AKST

HST

Legislator's State for Appointment(Required)

Legislator(Required)

How was this meeting conducted?

Phone Conference

Video Conference

In Person

Other

Please input other

Did the the Senator or Representative attend the meeting?

Yes

No

Staff Information

Please list the staff who attended this meeting

Staff Contact First & Last Name(Required)

First Last

Staff Contact Position/Title(Required)

Staff Contact Email(Required)

Staff Contact Phone Number(Required)

Were there additional staff members who participated in this meeting?

Yes

No

Fill in as many staff members as applicable

Additional Staff Member 1 First & Last Name

First Last

Additional Staff Member 1 Title

Additional Staff Member 1 Phone

Additional Staff Member 1 Email

Additional Staff Member 2 First & Last Name

First Last

Additional Staff Member 2 Title

Additional Staff Member 2 Phone

Additional Staff Member 2 Email

Additional Staff Member 3 First & Last Name

First Last

Additional Staff Member 3 Title

Additional Staff Member 3 Phone

Additional Staff Member 3 Email

Additional Staff Member 4 First & Last Name

First Last

Additional Staff Member 4 Title

Additional Staff Member 4 Phone

Additional Staff Member 4 Email

Additional Staff Member 5 First & Last Name

First Last

Additional Staff Member 5 Title

Additional Staff Member 5 Phone

Additional Staff Member 5 Email

Please list the staff member that should be contacted for follow-up:

First Last

Does the staff member to contact for follow-up already have contact information shown above?(Required)

Yes

No

Staff member for follow-up Email

Advocate Information

First Advocate - First & Last Name

Please list yourself as the First Advocate if you attended this meeting

First Last

Constituent of Legislator 1

Yes

Second Advocate First & Last Name

First Last

Constituent of Legislator 2

Yes

Third Advocate First & Last Name

First Last

Constituent of Legislator 3

Yes

Forth Advocate First & Last Name

First Last

Constituent of Legislator 4

Yes

Fifth Advocate First & Last Name

First Last

Constituent of Legislator 5

Yes

Appointment Feedback

How likely is it that the representative or senator will sign the Dear Colleague Letter?(Required)

Very Unlikely

Unlikely

Neutral

Likely

Very Likely

Were any other topics of relevance discussed? Please list specifics.

Were there any questions brought up in your meeting that need to be addressed or followed up on by the TS Alliance?

Yes

No

Please list the questions that were raised:

Please add any additional comments or feedback that you would like to share:

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8737 Colesville Road, Suite 400 Silver Spring, Maryland 20910-3921 USA 800.225.6872 (Toll-Free) 301.562.9890 info@tscalliance.org

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