Pennsylvania Optometric Association
Legislative Encounter Report
Doctor Name
Email
example@example.com
Legislator’s Name
Date of Encounter
/
Month
/
Day
Year
Date
Please check the box(es) that describe this encounter:
Fundraiser
Personal Check Amount
POPAC Check Amount
District Office Visit
Harrisburg Office Visit
Other (please describe)
Summary of Encounter/Comments/Recommended Follow-up:
Your legislator:
SAID he/she SUPPORTS optometry’s position on this issue.
SAID he/she does NOT support optometry’s position on this issue.
Was noncommittal on this issue.
This visit was not for a specific issue.
Issue(s)
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