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Health Care Letter
Please add your signature if you work in the health care industry. Please write any of your credentials in the first section with your full name. Thank you for advocating for our youngest children!
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Full name and title, any credentials and info on where you work--This is what will be publicly used: Examples: Jane Smith, MD / Jane Smith, ND, Children's Hospital / Jane Smith, work in rehab facility
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Your answer
Hospital or health/ science place you work at (This information will not be identified with you publicly)
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Your answer
Location (City, State)
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Your answer
Email
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Your answer
Phone
Your answer
Type of health care professional
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Administrative professional at health care facility
Licensed Practical Nurse
Medical Assistant
Mental Health Professional
Naturopathic Doctor
Nurse Practitioner
Occupational Therapist
Pharmacist
Physician
Physical Therapist
Physician Assistant
Respiratory Therapist
Registered Nurse
Scientist
Speech Pathologist
Other:
If marked "other" please specify below
Your answer
Are you signing on behalf of yourself or an organization?
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Myself
Organization
If you are signing on behalf of an organization, please write how you would like the organization to be listed. (Please note that we may verify directly with you or the organization that we can add the organization name to the letter).
Your answer
Would you like to help in other efforts to advocate for vaccines for children under 5?
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Yes
No
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