Event Feedback Form

Legislative Encounter Feedback Form 2018

Your feedback is essential to APRN Legislative Efforts in Georgia
You may click or copy and paste this link to look up your State Legislator Information:

http://openstates.org/find_your_legislator/
Date of the Encounter

MonthDayYear
What is your Georgia Senate Legislative District?
Name of Your State Senator

First NameLast Name
What type of encounter did you have with your State Senator?*
Overall, how would you rate the encounter with your State Senator? (Unfavorable 1 Star to Favorable 5 Stars)
Is your Senator supportive of the bill to establish an APRN Full Practice Authority Legislative Study Committee

Yes SupportiveNo AgainstUndecided
What other details of your encounter with your Senator would you like to share with APRN leadership and APRN lobbyist?
What is your Georgia Representative Legislative District?
Name of Your State Representative

First NameLast Name
What type of encounter did you have with your State Representative?*
Overall, how would you rate the encounter with your State Representative? (Unfavorable 1 Star to Favorable 5 Stars)
Is your Representative supportive of the bill to establish an APRN Full Practice Authority Legislative Study Committee

Yes SupportiveNo AgainstUndecided
What details of your encounter with your Representative would you like to share with APRN leadership and APRN lobbyist?
Please detail any Personal Stories you may have on how current Restrictions on APRN practice in Georgia is affecting your ability to give care to patients
Your Information:
Your Name

First NameLast Name
Your APRN Specialty(CNM, FNP, CNS, CNA) and Credentials (MSN, DNP, PhD, Student etc)
E-mail
Cell Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer
May we sign you up for Legislative Text Alerts when Calls to Action are needed?

YesNo
May we add you to CAPRN Legislative Email Listserve?

YesNo
Have you sent a follow up thank you note to your legislator following the encounter?

YesNo, not yetOption 3
Continuing Education Credit Hours Evaluation of L.E.A.D. Program and Georgia CAPRN Legislative Advocacy Efforts
Check All CAPRN.org Tools you utilized in preparation for your encounter:

Review of APRN of the Day Legislative Youtube VideoElevator Speech Essentials for Your First Encounter with your LegislatorStrategies for APRNs to Influence Their Legislators Screencast VideoAdvocacy Resources Materials at: http://caprn.org/advocacy/None
Rate the Teaching Effectiveness of the CAPRN Lobbyist Julianna McConnell with the skills of Legislative Education and Advocacy for Nurses?*

N/A Did not meet with CAPRN Lobbyist1 Not Effective2 Somewhat Effective3 Effective4 Very Effective5 Highly Effective
Rate the Teaching Effectiveness of the APRN of the Day Youtube Video in preparing you to participate in APRN of the day.

N/A did not watch the APRN of the Day video1 Not Effective2 Somewhat Effective3 Effective4 Very Effective5 Highly Effective
Do you have any suggestions on how we can better meet your APRN advocacy needs?
After completion of the L.E.A.D./APRN of the Day Program at the Georgia State Capitol, I have increased my legislative knowledge and advocacy skills.

Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
After completion of the L.E.A.D./APRN of the Day Program at the Georgia State Capitol, I plan to have follow up contact with at least one of my home district legislators at least once in the next 6 months.

Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
IMPORTANT TO RECEIVE YOUR CE: Please enter the number of Contact Hours you spent on this activity (4-7 hours). *including the 1 hour of Pre-Event Online Activities, your time actively participating in Legislative Activities (but not including the lunch break time period). You may document to the tenths or hundredths place, but you should not round up. Example: 2.75 or 2.7 Contact Hours, not rounded to 2.8
Any final comments?
Should be Empty:

Legislative Encounter Feedback Form 2018

You may click or copy and paste this link to look up your State Legislator Information:

Your Information:

Continuing Education Credit Hours Evaluation of L.E.A.D. Program and Georgia CAPRN Legislative Advocacy Efforts