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MEDIA
AVAILABILITY
FORM
Your input and information is a
valuable in promoting family practice and IAFP members as well as
handling media requests. Please take a few moments to complete the
following survey and return to Ginnie Flynn or fax to 630-435-0433
as soon as possible.
THANK
YOU!
Your Name:_________________________ Office Location (City): ____________________
Name of your
Practice:________________________________________________________
Hospital Affiliations:_________________________________________________________
Academic Affiliations:________________________________________________________
Other advisory boards or Commissions you
participate in:_____________________________
__________________________________________________________________________
_________________________________________________________________________
Would
you be willing to: (check all that apply)
PRINT
(NEWSPAPER/MAGAZINE) INTERVIEWS
_____in person _____via
phone
RADIO
INTERVIEWS (by phone ):
______live
______pre-taped ______
in-studio (radio show)
TELEVISION
INTERVIEWS ______pre-taped _______live
in-studio
OTHER MEDIA OPPORTUNISM
____attend
editorial board meeting ______
sign letter to editor
I AM USUALLY ABLE TO DO INTERVIEWS
DURING THE FOLLOWING DAYS/TIMES:
____________________________________________________
FASTEST/PREFERRED WAY TO REACH ME:
fill out all that apply
PHONE:
_______________________ (ask for): ______________________
PAGER:
_______________________FAX: ________________________________
EMAIL:
___________________________________________
Which healthcare topic(s)
and policy issues do you feel most qualified to discuss?
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