I AM WILLING TO TALK WITH A NEWSPAPER OR BROADCAST REPORTER ABOUT MY
EXPERIENCES WITH THE SURVIVOR BENEFIT PROGRAM AND THE IMPACT ANY OFFSET HAS HAD
ON MY LIFE: (PLEASE CHECK ONE)
YES________ N0__________
IF YOU ARE WILLING TO TALK WITH A MEMBER OF THE NEWS MEDIA, DO YOU WANT MOAA
TO CALL YOU FIRST BEFORE GIVING YOUR NUMBER OUT TO REPORTER? (PLEASE CHECK ONE)
CALL ME FIRST_________ DON'T NEED TO CALL ME FIRST____________
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CONTINUATION OF IMPACT NARRATIVE (IF NEEDED): _________________________________
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