POA Legislative Contact Sheet

POA Legislative Contact Sheet
The Pennsylvania Optometric Association is in the process of updating and fine-tuning its legislative contact (“Keyperson”) network. This is the network by which our grassroots – our members – contact legislators when there is an immediate need. To be politically effective, we need to establish records that indicate which POA members are contacting or will contact their Pennsylvania legislators whenever we have urgent Calls to Action or other important information. This will help us identify any gaps that we will need to fill by some other method. We also would like to know the level of your relationship with the legislators you typically contact and the type of contact you have with this legislator. Our database system will allow us to use this information internally to maximize our effectiveness. This information will not be shared outside the POA office.

Please complete a separate form for EACH legislator you know and contact. This is for both Pennsylvania Representatives or Senators and U.S. Congressmen.
Your Name
Email
example@example.com
State Representative, Senator or Member of Congress
Check which applies

This is my home voting district legislatorThis is the legislator where my office is locatedBoth my home and office are located in his/her districtThis is a legislator who I know but does not fit either of the above situations
Please check one only for your preference of the following:

I am willing to be a keyperson contact for this legislator (This means you will try to always respond to action alert by calling this legislator) ORI am willing to be an active contact for this legislator (This means I will try most of the time to respond to an action alert by emailing or faxing this legislator)Will contact when I can
Please check the following that apply to your relationship with this legislator:

I have personally contacted this legislatorWe attend the same church/synagogue/mosqueHe/she is a close personal friendWe are in the same club or organizationHe/she is a casual friendHe/she has a relative who works with a relative ofHe/she is a relativeHe/she is a neighborOur kids know each otherWe serve on a same board/committeeHe/she has visited me at my officeHe/she is a patientI financially contribute to his/her campaignI have helped on his/her campaign
Other: describe any other relationship you might have with this legislator
Insert a number from 1 to 5 which indicates the strength of your relationship with this legislator on a scale of 1 to 5, with 1 being very weak and 5 being very strong
Thank you for your help -- it will ultimately benefit you and your profession!
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