PHAware Media Evaluation Form

Name: Address: City: State: Zip: Phone: E-mail:
Which activity did you participate in?
News Release	Op-Ed	Letter-to-the-Editor	Interview	Radio PSA
Publication/ Station: Reporter: Address: Phone: Date of Contact: E-mail:   Publication/ Station: Reporter: Address: Phone: Date of Contact: E-mail:   Publication/ Station: Reporter: Address: Phone: Date of Contact: E-mail:   Publication/ Station: Reporter: Address: Phone: Date of Contact: E-mail: Do you plan on keeping any of the reporters informed on PH community developments? Who? 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 PHAware program? xxxxx

Patients | Medical Professionals | Caregivers | Media

The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs. Questions about the site? email web@PHAssociation.org Pulmonary Hypertension Association 801 Roeder Road, Ste. 400 Silver Spring, MD 20910 Copyright © 2008 Pulmonary Hypertension Association Read our privacy policy.

For optimal viewing of PHAssociation.org we recommend the following:

PC : Windows running Internet Explorer 5.5 or higher Macintosh: Internet Explorer 5.2 or higher free download from Microsoft.com   Macromedia Flash Player free download from Macromedia.com   Adobe Acrobat Reader 6.0 or higher free download from Adobe.com