PHAction Government Evaluation Form

Name: Address: City: State: Zip: Phone: E-mail:
Which activity did you participate in?
Call	Letter	Visit
Elected Official: Health LA: Address: Phone: Date of Contact: E-mail:   Elected Official: Health LA: Address: Phone: Date of Contact: E-mail:   Elected Official: Health LA: Address: Phone: Date of Contact: E-mail:   Elected Official: Health LA: Address: Phone: Date of Contact: E-mail: Please list the elected officials you plan to keep informed on PH community developments. Would you like to be a PHAction mentor and share your experience with others on the PH community who are interested in participating in similar action? Yes No Do you have any suggestions concerning this PHAction program? xxxxx

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