Advocacy Report Back Form

Please take a few minutes to let us know how you are advancing our federal and state legislative priorities with lawmakers and candidates for office.

These report back forms help us reply to any questions or concerns your legislators and candidates might have and to adjust our legislative campaign strategy, so please be as detailed as you can.

Personal Information

First Name:

Last Name:

Email Address:

State:

Report Your Impact on Lawmakers & Candidates

Are you reporting activity related to a federal or state lawmaker or candidate?

Federal

State

Name of lawmaker or candidate:

Date activity occurred:

Issues Discussed

What specific issues were discussed?

Access to quality healthcareAccess to safe and effective treatmentsAffordability of care and coverageQuality of lifeOther(select all that apply)

Other, please explain:

Action Taken

What types of actions were taken?

Office meeting with a lawmaker, candidate or their staffVirtual meeting with a lawmaker, candidate or their staffOffice drop-byHandwritten letterPersonal emailText messagePhone callTagged lawmaker or candidate on social mediaAsked a question at a townhall or other meetingCollected petition signaturesTestified at a public hearingSecured a new co-sponsorSubmitted a letter to the editor or other opinion pieceOther

Other, please explain:

More Information

What was your specific ask/request?

What response did you receive? (Optional)

Is there any type of follow up required? (Optional)

Is there anything else we should know about this activity? (Optional)

Connection to Bleeding Disorders Community

Do you have a bleeding disorder?

Yes

Please specify your Bleeding Disorder Type: (check all that apply)

VIII (8)	IX (9)	von Willebrand (vWD)
vWD Type 1	vWD Type 2	vWD Type 3
I (fibrinogen)	II (prothrombin)	V (5)
VII (7)	X (10)	XI (11)
XIII (13)	Platelet Disorder	Other

Are you a caregiver of a person with a bleeding disorder?

Yes, I'm a parent of a person with a bleeding disorder.Yes, I'm a partner/spouse of a person with a bleeding disorder.