JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Health Workers & Patients, Share Your Story!
Our personal stories are a powerful organizing tool that can be highly effective in inspiring others, including our legislators, to take action. Thank you for sharing!
Below are a few optional prompts to help shape a compelling story for single payer advocacy, including a place to share a short quote for our
#MedStoryMonday
series.
Please share this form with others!
www.bit.ly/MedStoryMonday
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
What is your first name?
*
Your answer
What is your last name?
*
Your answer
Please fill out the optional prompts below
& feel free to ignore prompts that do not apply to your story. Examples are in parenthesis after each prompt.
When I was / As a / I was working at a...
(framing specific to your story; your age, job/immigration/health status, stage in life, person in X profession, person living in X location, etc.)
Your answer
I sought care for / was diagnosed with / witnessed / cared for a patient with...
(chronic migraine, health emergency, long term care, mental health crisis, etc.)
Your answer
I experienced /
I was forced to...
(wait months to be seen in a free clinic, stop cancer treatments, delay or not get preventative care, spend hours on the phone etc.)
Your answer
Due to...
(The high cost of co-pays, could no longer afford insurance, lack of adequate insurance coverage, lost insurance because of job status,
no doctors available in my network,
etc.)
Your answer
I support the New York Health Act & Medicare For All because...
(people deserve healthcare regardless of their income, I don't want others to lose x the way I did, etc.)
Your answer
How would winning universal single-payer healthcare change your life or the lives of your loved ones, colleagues, or patients?
(2-5 sentences)
Your answer
Submit a concise (2-4 sentence) anecdote/quote for our #MedStoryMonday series!
We will be in touch to request a photo!
Your answer
Do we have your permission to use your story publicly?
*
Yes
No
Other:
What is your phone number?
Your answer
Street Address, City/Town, Zip code
Your answer
Title (ex: MD, RN, CNM, PhD, CPA, etc) and/or role (ex:
teacher, line cook, delivery worker, farmer,
family doctor, pediatric nurse, medical student, resident, etc.)
Your answer
What is your relationship to the health system? (check all that apply)
Physician
Registered Nurse
Resident MD
Medical Student
Social Worker
Midwife
Doula
Union Member
Homecare Worker
Public Health / Policy
Hospital Housekeeper
Advocate
Patient
Other:
Optional: Would you like to get involved with PNHP?
There are lots of ways to help, EX: writing, tech team, social media team, translation, research, phonebanking, etc.
I would like to:
help by Writing Op-Eds or Letters to Editors (training available)
attend a training on Storytelling for Advocacy
get the toolkit for tabling for the New York Health Act
receive information about PNHP NY Metro's working groups
receive information about the PNHP New York Metro chapter's UHLAF fellowship (Universal Healthcare Legislative Advocacy Fellowship)
Other:
Please feel free to submit additional stories via this form at any time.
Thank you! Click "submit" below to finalize.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
