The American Pain Foundation:

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ADVOCACY SURVEY

Thank you for your interest in joining with us to advocate for the elimination of the undertreatment of pain. It is not acceptable that millions of Americans suffer with pain and the majority of people do not receive appropriate care. Pain does not discriminate; it cuts across race, age, gender and medical conditions. By working together we can build and leverage a tremendous voice for change.

There are many ways you can volunteer and help! By completing this form, your information will:
*Guide our efforts
*Let us know how you would like to be involved, and
*Assist us in determining how to best target your advocacy interest/experience as it is needed on important issues.

By uniting our voices for hope and power over pain, together we can create change!

(We take your privacy seriously and know it is important to honor. We will not sell or rent this information to others. We will share this information only with your permission. For more information about our privacy policies, click here.)

Please tell us:

Name:

First Required	Middle Required	Last Required

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number: Required

Gender:

Date of Birth:

Month

Day

Year

If you respond and have not already registered, you will receive periodic updates and communications from The American Pain Foundation.

Remember me. What's this?

Question - Not Required - What is the preferred method of contact to reach you about actions that need to be taken for pain issues?

	Email
	Telephone

Question - Not Required - What is your race/ethnicity? (This question is optional but we are making all attempts to make sure all groups are represented.)

Question - Not Required - Are you a veteran or member of the United States military?

Question - Not Required - I am a: (Please check all that apply)

	Person with Pain
	Family Member/Loved One
	Caregiver
	Healthcare Professional
	Other Professional
	Concerned Public

Question - Not Required - What is the primary source of your pain (or that of your family member/friend)?

Question - Not Required - I AM INTERESTED IN/WILLING TO (whether you are a person with pain, friend, professional or other, please check one or all!) EDUCATE ELECTED OFFICIALS:

	Write letters (via emails) to legislators
	Write letters (via postal mail) to legislators
	Make phone calls to legislators
	Visit legislators' offices to speak with them personally
	Testify at legislative meetings

Question - Not Required - With which, if any, of these do you have experience?

	Write letters (via emails) to legislators
	Write letters (via postal mail) to legislators
	Make phone calls to legislators
	Visit legislators' offices to speak with them personally
	Testify at legislative meetings

Question - Not Required - I AM INTERESTED IN/WILLING TO INFLUENCE THE MEDIA:

	Write a letter "to the editor"
	Be interviewed for print
	Be interviewed for radio
	Be interviewed for tv
	Be interviewed for video

Question - Not Required - With which, if any, of these do you have experience?

	Write a letter "to the editor"
	Interviewed for print
	Interviewed for radio
	Interviewed for tv
	Interviewed for video

Question - Not Required - I AM INTERESTED IN/WILLING TO SPEAK OUT/TALK WITH:

	Community Groups
	Religious Organizations
	Local Hospitals/Staff
	Participants of conferences/workshops
	State Pain Initiatives
	Support Groups

Question - Not Required - With which, if any, of these do you have experience?

	Community Groups
	Churches, Synagogues
	Local Hospitals/Staff
	Participants of conferences/workshops
	State Pain Initiatives
	Support Groups

Question - Not Required - I AM INTERESTED IN/WILLING TO ORGANIZE/BE A PART OF A GRASS ROOTS EFFORT IN MY COMMUNITY:

	Encourage other individuals and groups to get involved in APF activities
	Represent another organization/group in APF activities
	Hold public forums on pain
	Bring pain awareness activities to your state
	Be an APF Action Network State Leader (coordinator/point person for advocacy activities)

Question - Not Required - With which, if any, of these do you have experience?

	Encouraged other individuals and groups to get involved in APF activities
	Represented another organization/group in APF activities
	Held public forums on pain
	Participated in public awareness activities
	Functioned as a ccoordinator/point person for advocacy activities

Question - Not Required - DO YOU HAVE A RELATIONSHIP/ASSOCIATION WITH ANY FEDERAL LEGISLATORS ?

Question - Not Required - If so, please list who and briefly describe the relationship:

Question - Not Required - DO YOU HAVE A RELATIONSHIP/ASSOCIATION WITH ANY STATE LEGISLATORS?

Question - Not Required - If so, please list who and briefly describe the relationship:

Question - Not Required - WHAT ORGANIZATION(S) ARE YOU OR HAVE YOU BEEN A VOLUNTEER? Please list:

Question - Not Required - In which of these activities have you participated with this/these organization(s)?

	Educator/Trainer
	Event Coordination/Management
	Legislative Advocacy
	Public Speaking
	Other

Question - Not Required - IF YOU ARE A PERSON WITH PAIN, ARE YOU WILLING TO SHARE YOUR PERSONAL STORY WITH THE PUBLIC?

Question - Not Required - What message of hope would you give to the public and people with pain (250 words or less):

Question - Required - I would like to participate in advocacy activities and I give APF permission to share my contact information with a Action Network Leader in my state. Your information will not be shared with or distributed to anyone else without your explicit consent. If there is currently not an active leader in your state, we will store your survey and forward it when an active leader is available.

Question - Required - To reduce spam and increase security, please type the text you see in the box provided.

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By joining with the American Pain Foundation, your voice, along with thousands of others, will collectively raise public awareness and promote the best pain policy, legislation and practice.

Thank you very much for your participation in this important effort. We look forward to working with you. Together we can create change!