Q.1
Name:
*
First Name
Last Name
Q.2
Where Published?
*
City
State
Q.3
Your Email:
*
Email
Q.4
Media Type:
*
Newspaper
Magazine
Radio
TV
Web
Other:
Q.5
Classification:
*
Letter to the Editor
Op-ed
Editorial Meeting
Editorial Published
Blog
Interview
PSA
Other:
Q.6
Media Name (i.e. New York Times):
*
Q.7
Web Link to your Media (if any):
Q.8
Date Submitted (if known)
MM
Jan
Feb
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/
YYYY
Q.9
Date Published
MM
Jan
Feb
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Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
DD
01
02
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/
YYYY
Q.10
What was the theme/legislation focus of your piece?
*
Q.11
If this was monthly action, which month?:
Q.12
Any additional Comments?