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The information you provide will be used to better inform advocacy efforts and to educate lawmakers during our Storm the Hill Week of Action.

Stay tuned for dates and asks because we need all hands on deck, including family, friends, and allies to achieve legislative change!

Fort Ord Questionnaire

For individuals impacted by the contamination at Fort Ord US Army base who are willing to share their story.

First Name

Email Address

Last Name

Phone

Are you completing this for yourself or someone else *

Myself

Someone else

If someone else, what is your relationship to the impacted individual?

Which of the following best describes how you are connected to the Fort Ord contamination? * Required

On Active Duty

As a spouse

As family other than spouses

As a civilian worker

Living nearby

Other

If other, please specify

Dates of Exposure at Fort Ord

Describe the location of exposure as specifically as possible

What is or are the condition(s) or diagnosis(es) you believe is/are related to the contamination?

What was the age at diagnosis?

Residential Zip Code

Is the impacted individual *

Living

Deceased

If deceased, age and cause of death.

If applicable, has a VA claim for service connection been filed?

Yes

No

Planning to

If a claim was submitted, what is the status?

Approved

Denied

Pending

Please describe how you were exposed, ie your MOS and occupation on base.

Is there anything else you would like your lawmakers to know?

By checking this box, I certify that I am the impacted individual or someone with express permission to respond on their behalf. I grant permission for On Your Side Action to share my answers with lawmakers and their staff for meeting requests, education, and advocacy purposes. I understand that this information will not be redacted and consent to this limited disclosure for advocacy purposes. This authorization shall be in effect for 3 years from the date of submission. Any other uses of data shall be redacted and deidentified--information will not be used for solicitation.

Initials

Today's Date

If you wrote a letter to your lawmaker that you'd like to share, upload here.

Upload File

Upload supported file (Max 15MB)

Thanks for submitting!

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