Grassroots Activity Report Form

Fill out this form when you send a personal letter, host a practice visit, attend a town hall meeting, or otherwise meet with one of your legislators. Completing this form allows APTA staff to track actions being taken by members and follow up with members of Congress and their staff.

Meeting Date:  [None] Select a Date Delete the Date
 
Name:  
Member Number:  
Address:  
Email:  
Met With:  
Location of Meeting:  
Was Legislator Present:
                
 
Key Staff Present:
                
 
Bill(s) & Number Discussed:  
Issues Discussed:   
   
     
     
     
    
Other:  
Legislator/LA Response:  
Position on Bill Discussed:  
Follow-up Planned:
                
 
If applicable, how does Government Affairs need to follow-up on meeting? (call, materials, etc.)  
Additional Comments:  

 
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American Physical Therapy Association | 1111 North Fairfax Street, Alexandria, VA 22314-1488 703/684-APTA (2782) | 800/999-2782 | 703/683-6748 (TDD) | 703/684-7343 (fax)