First Name


Last Name


Local Number


Member Number


Phone Number


Email Address


Topic (General Campaign Feedback/Community Screening Event)


Date of Event (if contacting for Community Screening Event)


Location of Event (if contacting for Community Screening Event)


Screenings Conducted at Event (if contacting for Community Screening Event)


Local Media Attending or Covering Event (if contacting for Community Screening Event)


Community Feedback on Event (if contacting for Community Screening Event)


Likelihood to Conduct an Event in the Future (if contacting for Community Screening Event)


Plans to Conduct an Event in the Future (if contacting for Community Screening Event)


General Feedback:

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Novartis Pharmaceuticals Corporation ("Novartis") is asking you to provide your contact information and local IAFF number in order to contact you directly about your use of the Stop Drop Control High Blood Pressure Program. Additionally, Novartis may contact you about future programs that Novartis may sponsor from time to time. Your email address and phone number will not be used for any other purpose. You may ask us to remove your name and address from future contacts at anytime by calling Novartis at 1-877-352-6474, extension 2-9111 or emailing Novartis at stop.dropcontrol@novartis.com.