Pain Awareness Month/National Day of Action Activity Report

This easy-to-complete report has been designed to capture the wonderful outreach and advocacy you did during September. Fill this out and be counted! If you do not have an answer for a question simply place a '0' in the text box or leave it blank. Thanks for all you are doing to improve pain care and thanks for taking the time to let us know about it.

Question - Not Required - Community Outreach - please check the box(es) that best describe any outreach you did in this focus area (check all that apply):
Please make up to 5 selections from the choices below.

	Talked to my family, friends, health care provider, colleagues, or faith community about this issue
	Signed the National Day of Action petition and/or forwarded the petition request to others and asked them to sign/get involved
	Hosted/worked at a pain exhibit (e.g. - had a booth at local health fair, set up exhibit in hospital lobby)
	Hosted/attended a community event or gathering of some sort
	Blogged or wrote about Pain Awareness Month/National Day of Action on social networking site(s) (e.g. - Blogspot, Facebook, Twitter, etc)

Question - Not Required - Please describe your work in your community. If you had an event, please write the name of the event, when and where it took place, and how many people attended. If you did not have a specific event, please describe the ways you reached out in your community.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Please indicate how many people to whom you forwarded the petition. If you forwarded it to any organizations, please list them.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - If you are a member of an organization that linked to the petition or included a message about Pain Awareness Month and/or the National Day of Action in communication with your membership, please list the name of the organization and describe the type of posting that was made. Example: Ohio Nurses Association circulated the website and petition link via our listserv.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Please list the social networking sites you used to spread the word:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - If you distributed any American Pain Foundation materials as part of your activities to spread awareness this September, approximately how many did you distribute?

Question - Not Required - Policy Advocacy - please check the box(es) that best describe any work you did in this focus area (check all that apply):
Please make up to 3 selections from the choices below.

	Called, e-mailed, sent a letter to, or met with my legislator
	Secured a Pain Awareness Month proclamation for my state or city
	Organized, helped to organize, or responded to a policy-related APF Alert

Question - Not Required - Please list the legislators contacted and/or the name of the city or state for which you secured a proclamation.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Media Advocacy - please check the box(es) that best describe your efforts in this focus area (check all that apply):
Please make up to 3 selections from the choices below.

	Submitted a Public Service Announcement (PSA) to local media
	Submitted a letter to editor, media alert, or opinion-editorial to my local paper
	Told my story to print, radio, TV, or web media

10.

Question - Not Required - Please list the name of the publication/media outlets and the dates the story or PSA ran/aired. If possible, please provide a web link to blog/article/podcast:

(Maximum response 255 chars, approx. 5 rows of text)

11.

Name and Contact information are:

Name: