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Legislative Visit Report
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* Indicates required question
Name
*
Your answer
Email
*
Your answer
Your Primary Practice Setting
*
Choose
Outpatient Clinic
Specialty Clinic
NP Owned Clinic
MD Owned Clinic
Hospital
School Based
Education
Do you own your own practice?
*
Yes
No
Legislator's Name
*
Your answer
Was the legislator familiar with NP's in Louisiana and their role in the healthcare system?
*
Not at all
1
2
3
4
5
6
7
8
9
10
Yes, completely familiar with NP's
If needed, please add additional details & information regarding the previous question.
Your answer
Was the legislator open to legislation to remove the collaborative practice agreement for NP's?
*
Not at all
1
2
3
4
5
6
7
8
9
10
In complete agreement with CPA removal
If needed, please add additional details & information regarding the previous question.
Your answer
Would you be willing to be listed as the key contact person for outreach to this legislator in the future?
Yes
No
Clear selection
If no to previous question, why?
Your answer
Did the legislator mention a relationship with other NP's?
Yes
No
Clear selection
If yes to previous question, please list his relationships and who. (ex. niece is an NP in Jefferson Parish, see an NP as his primary care provider, etc.)
Your answer
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