Camp Lejeune Community Impact Survey

Camp Lejeune Community Impact Survey

Help us show Congress how many people in their own communities have been affected by Camp Lejeune. The information you provide may be used to support advocacy and outreach to members of Congress and congressional staff. We will not publicly share your personal contact information without your permission.
Please provide as much information as you are comfortable sharing. Your address is especially important because it allows us to identify your congressional district.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Mailing Address

Street Address

Street Address Line 2
CityStateZIP Code
How are you connected to Camp Lejeune?

Other
Approximately when were you, your family member, or the person you know affected at Camp Lejeune?
Have you, someone in your family, or someone you know experienced a serious health condition that you believe may be related to Camp Lejeune exposure?

Other
If you selected "Yes," what is the health condition?
May we contact you regarding Camp Lejeune advocacy, research opportunities, community updates, or related efforts?
Acknowledgment

Please provide as much information as you are comfortable sharing. Your address is especially important because it allows us to identify your congressional district.