Policy Advocacy Assignment

Policy Advocacy Assignment Part A – Week 2
Note: This form is auto-enabled for editing. Please click within the area identified as “Click or tap here
to enter text.”
Please be sure to contact your legislator’s office to schedule a phone interview, live interview, or email
request for information.
Please complete the following form for this part of the two-part assignment:
1. Student Name: Click or tap here to enter text.
2. Name of the legislation to be advocated: Click or tap here to enter text.
3. Name of the State: Click or tap here to enter text.
4. Is this bill/law considered a piece of State Legislation? (click in the appropriate box to select)
i. ☐ Yes ☐ No
5. Is this bill/law considered a piece of Federal bill/law? (click in the appropriate box to select)
i. ☐ Yes ☐ No
6. Name of the bill/legislation: Click or tap here to enter text.
7. Where is the bill to be voted on:
i. ☐ House of Representatives ☐ Senate
8. Identify the name of the legislator to be contacted: Click or tap here to enter text.
a. Provide the URL link to the legislators web page: Click or tap here to enter text.
9. Describe your stance on the legislation and what impact this legislation has on healthcare
(patients and nursing profession) (less than 200 words).
Click or tap here to enter text.