Maine Providers for Gun Safety - Provider Story Collection
We are collecting physician & advanced practice provider stories in advance of legislative hearings on gun violence safety proposals.  By submitting testimony below, you are authorizing Maine Providers for Gun Safety to: share your comments with elected officials or in public hearings, publicly post your comments on our website, and/or excerpt them on social media and edit for length as needed.

The American Academy of Pediatrics recently conducted a similar exercise prior to a senate hearing on gun safety - their responses can be read here.

Due to the rapidly approaching legislative session which begins on January 3rd, our timeline is tight.  Please complete your submission as soon as possible.
Sign in to Google to save your progress. Learn more
Email *
Name (including MD, DO, PA, NP, etc) *
City/Town *
Specialty *
Please frame your submission in the following way: Open by stating your name, city/state, and specialty/type of practice.  Then, simply share a story about how gun violence has impacted your life, your work, your patients, or your community.  This can be one especially memorable patient encounter or snapshots of several moments where you saw firsthand how gun violence harms your patients. In your own words, write about your experience in a tone that conveys urgency and passion but remains respectful and professional.  Rather than focus on a specific policy solution, we recommend your call to action to be a high level ask for our elected leaders to address gun violence in our children's and patient's lives.  Please aim to submit a draft between 200-600 words below.  Thank you for taking the time to share your story. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms