Long COVID Sign-On Letter Form

This survey is to gather information regarding the organizations signing onto the Call to Action urging the development of a federal commission to create and implement a national plan to defeat the post-acute sequelae of SARS-CoV-2 infection (PASC) or "Long COVID" crisis. If your organization would like to sign on to this Call, please fill out the below questions so we may appropriately acknowledge your organization's support. Thank you for your attention to this issue.

1. What is your organization name? Please write it as you would like it to appear on the sign-on. *This question is required.

2. Name of individual filling out this survey. (First Last) *This question is required.

3. Title of individual filling out this survey. *This question is required.

4. Email address of individual filling out this survey. *This question is required. This question requires a valid email address.

5. Do you have sign on authority on behalf of your organization? *This question is required.

6. Which best describes your organization? *This question is required.

My organization represents patients
My organization represents clinicians
My organization is an academic medical center
My organization represents patient caregivers
Other - Write In Please enter an 'other' value for this selection.

7. Approximately how many members does your organization have (if applicable)?

8. Date of sign on. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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9. In addition to adding your organization's name to the Call to Action sign-on, can we include your organization name on our Long COVID webpages? *This question is required.