Exit VAFP Key Contact Survey - Make the Voice of Family Medicine Heard! Question Title * 1. Please enter your contact information below. First Name Last Name Suffix (MD, DO, FAAFP, etc.) Practice/Institution Name Home Address Home City Work Address Work City E-mail Phone Question Title * 2. How well do you know your home/workplace's district Delegate or Senator? Not at all Know by name only Have had occasional direct contact with my Delegate or Senator I am in regular contact with my Delegate or Senator My Delegate or Senator is a patient of mine Other (please specify) Question Title * 3. Please list any legislators with whom you presently have a relationship. Question Title * 4. Would you like to be a key point of contact for your legislator on family medicine issues? Yes No Question Title * 5. Do you have any additional comments regarding the Key Contact Program or the VAFP's Political Action Committee FamDocPAC? Submit