American Diabetes Association: Survey - Join the Advocacy Attorney Network

1.

Question - Not Required - Your Professional Website

(Maximum response 255 chars, approx. 5 rows of text)

2.

Question - Not Required - Place of Business

(Maximum response 255 chars, approx. 5 rows of text)

3.

Question - Not Required - Work Phone

4.

Question - Not Required - Mobile Phone

5.

Question - Not Required - In which state(s) you are licensed to practice law

	AK
	AL
	AR
	AZ
	CA
	CO
	CT
	DC
	DE
	FL
	GA
	HI
	IA
	ID
	IL
	IN
	KS
	KY
	LA
	MA
	MD
	ME
	MI
	MN
	MO
	MS
	MT
	NC
	ND
	NE
	NH
	NJ
	NM
	NV
	NY
	OH
	OK
	OR
	PA
	RI
	SC
	SD
	TN
	TX
	UT
	VA
	VT
	WA
	WI
	WV
	WY
	none

6.

Question - Not Required - In which states you are willing to volunteer

	AK
	AL
	AR
	AZ
	CA
	CO
	CT
	DC
	DE
	FL
	GA
	HI
	IA
	ID
	IL
	IN
	KS
	KY
	LA
	MA
	MD
	ME
	MI
	MN
	MO
	MS
	MT
	NC
	ND
	NE
	NH
	NJ
	NM
	NV
	NY
	OH
	OK
	OR
	PA
	RI
	SC
	SD
	TN
	TX
	UT
	VA
	VT
	WA
	WI
	WV
	WY
	none

7.

Question - Not Required - What is your practice setting?

Sole Practitioner

Private firm - office of 2 - 25 lawyer

Private firm - office of 26-50 lawyer

Private firm - office of 50+ lawyer

Government Agency

Nonprofit Organization

8.

Question - Not Required - What types of law do you practice

	Administrative
	Civil Rights
	Corporate
	Criminal Defense
	Disability Rights
	Discrimination
	Education
	Employee Benefits
	Employment
	General Practice
	Health Care
	Labor
	Personal Injury
	Prisoners Rights
	Unemployment
	Other

9.

Question - Not Required - Other law practice

(Maximum response 255 chars, approx. 5 rows of text)

10.

Question - Not Required - What specific discrimination law experience do you have?

	Employment
	Education
	Daycare/Childcare
	Correctional Facilities
	Police Misconduct
	Public Accomodations
	Drivers Licenses
	Other
	None

11.

Question - Not Required - Other (discrimination law experience)

(Maximum response 255 chars, approx. 5 rows of text)

12.

Question - Not Required - Do you provide legal services in languages other than English?

13.

Question - Not Required - If yes, please list additional language(s0 in which you provide legal services

(Maximum response 255 chars, approx. 5 rows of text)

14.

Question - Not Required - In which following functions are you interested in providing service as a Network Member?

	Providing legal consultations
	Making phone calls
	Writing letter
	Litigating cases
	Consulting on cases
	Assisting with legislative efforts
	Educating individuals about their rights
	Presenting information about Advocacy Attorney Network to others
	Helping to recruit new members of the Advocacy Attorney Network

15.

Question - Not Required - Are you able to provide a free consultation to individuals referred to you by the Association?

16.

Question - Not Required - In general, after initial consultation, what fee structure(s) are you able to consider?

	Pro bono
	Contingency
	Flat fee
	Hourly rate
	retainer
	All of the above
	Other

17.

Question - Not Required - Other (fee structure) explain

(Maximum response 255 chars, approx. 5 rows of text)

18.

Question - Not Required - How did you learn about the Advocacy Attorney Network?

Professional Colleague

Presentation at conference/meeting/other event

American Diabetes Association

ADA Advocacy Attorney Network Business Card

Family/Friend

Other

19.

Question - Not Required - Other (how did you learn)

(Maximum response 255 chars, approx. 5 rows of text)

20.

Question - Not Required - What was the primary motivation for you to become a member of the Advocacy Attorney Network?

I have a strong personal connection to diabetes

I wanted to volunteer/advocate for an important cause

I wanted to leverage my professional skills/experience in a meaningful way

Other

21.

Question - Not Required - Other (why involve)

(Maximum response 255 chars, approx. 5 rows of text)

22.

Question - Not Required - Have you been involved with ADA?

	Joined the Stop Diabetes movement
	Subscribed to Diabetes Forecast magazine
	Subscribed to a professional member publication
	Subscribed to e-newsletters
	Volunteered
	Attended a Diabetes EXPO
	Made purchase from ADA online store
	Participated in Step Out
	Participated in a Tour de Cure
	Child attended a Diabetes Camp
	Participated in an online message board
	Participated in School Walk for Diabetes event
	Other

23.

Question - Not Required - Other (participation)

(Maximum response 255 chars, approx. 5 rows of text)

24.

Question - Not Required - Do you want to become Diabetes Advocate

25.

Question - Not Required - If you want to recommend a colleague for us

26.

Question - Not Required - Ready to Sign Up?

27.

Question - Not Required - first name

28.

Question - Not Required - last name

29.

Question - Not Required - email

(Maximum response 255 chars, approx. 5 rows of text)

30.

Question - Not Required - street 1

(Maximum response 255 chars, approx. 5 rows of text)

31.

Question - Not Required - city

(Maximum response 255 chars, approx. 5 rows of text)

32.

Question - Not Required - zipcode

33.

Question - Not Required - phone

34.

Question - Not Required - occupation

35.

Question - Not Required - state

36.

Question - Not Required - In which of the following areas are you interested in providing service, as a Network Member?

	Employment
	Education
	Daycare/Childcare
	Correctional Facilities
	Police Misconduct
	Public Accomodations
	Drivers Licenses

37.

Question - Not Required - listserv opt in