Survey - American Lung Association in Washington LLB Survey - American Lung Association of the Mountain Pacific

Fighting for Air Online

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1. Contact Information:

Name:

Title	First Required	Last Required	Suffix

Email: Required

Address Line 1: Required

Address Line 2 (Optional):

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

Employer:

Gender:

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___________________________________

Question - Required - 2. How many years have you served on the Local Leadership Board?

Question - Required - 3. Age:

Question - Required - 4. Race/Ethnicity (Enter only one category):

Question - Required - 5. Industry (Enter only one category):

Question - Required - 6. Area of Expertise (Check all that apply)
Please make at least 1 selection from the choices below.

Question - Required - 7. Relationships (Check all that apply):
Please make at least 1 selection from the choices below.

	Access to Revenue Sources
	Access to Healthcare Community
	Access to Corporate Leaders
	Access to Community Leaders
	Other

If you have any questions about the survey or the form, feel free to call Season Oltmann at 206-512-3293 or email her at Season.Oltmann@Lung.org.