State Legislative Action Alert Form
Fill out and e-mail the form to Craig Price at cprice@acep.org and/or Melissa Ehrman at
mehrman@acep.org. The State Legislative Office will load the information onto the ACEP Action Alert
System and send you a link that you can then send to your chapter members. The link will take the
members directly to the alert page where they can quickly and easily e-mail the chapter’s message to their
state officials.
1. Identify Which Branch or Body the Correspondence is Directed To: (Governor, State
Senators, State Representatives, Specific State Regulatory Agencies, etc.)
2. Create a Title Headline (and optional sub-headline) for the Message Your Chapter
Members Will See When They are Directed to the CapWiz Site (for example, “Contact Your
State Legislator to Urge Support for HB1234”)
Headline:
Sub-headline:
3. Provide Beginning and Ending Dates for your Action Alert to Run:
Beginning:
End:
4. Message to Chapter Members: (This will be the full message that the chapter members first see
when they click on the action alert. This message should provide information describing the bill
or issue and its importance. Possibly include the bill number, the significance of the issue to
emergency medicine in the state, the time sensitivity of the issue, encouragement to send a
message to their legislator—or other state policymaker—, and whether members should consider
customizing the e-mail message that is provided for them—if you want to give them that
capability.)
Text of Message:
_
5. Do you want your chapter members to be able to edit the e-mail message you’ve created or
do you want them to send it only as it is currently written?
____ Allow them to edit it
____ Don’t allow them to edit it so they will send the message exactly as you’ve written it
6. Provide one or more subject line for every message that government official(s) will receive
from all of your chapter members. If more than one subject line, the CapWiz system can
rotate different subject lines from different users (Or leave blank to let each chapter
member create their own subject line in the e-mails they send):
___
___
7. If you provided a subject line for every e-mail message that government official(s) will
receive from all of your chapter members, would you like to give each chapter member an
option to edit the subject line (yes or no)?
___
8. Provide Bill Number Associated with the Action Alert:
_
___
9. Contents of Letter to Legislator: (Creating a letter greatly simplifies the process for your
members to easily contact their legislators and ensures that key messages are present. You can
create a letter or just bullet points that members can then insert. In your description of the issue
above, you may want to encourage members to edit the letter to include their own personal
comments. Personalizing the letters helps prevent creating an impression that this a “mass
mailing” of “form letters.” You want the letter to make your key points without being too long.
Attach separate page if needed.)
10. If you want a copy of e-mails that are sent to legislators forward to the chapter, please
indicate the name and e-mail address of the person in the chapter who should receive these
copies?
Name: _____________________________________________________________
E-Mail Address:
________________________________________________
11. Provide Name and E-Mail Address for Contact Person in the Event a Member has
Questions About the Alert
Name:
E-Mail Address: