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ONC Speaker Request
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Please Note: We ask that you submit your speaker request 6 to 8 weeks in advance of your event. We may not be able to accommodate short notice speaking engagement requests. Thank you.
s
Requested Speaker
Requested Speaker's First Name (
*
):
Requested Speaker's Last Name (
*
):
If the requested speaker is not available, are you interested in requesting another speaker?
--None--
Yes
No
Second Speaker First Name (
*
):
Second Speaker Last Name (
*
):
Event Date and Time
Date of Speaking Engagement (mm/dd/yyyy)(
*
):
Start Time:
End Time:
Time Zone (
*
):
--None--
Alaska
Central
Eastern
Mountain
Pacific
Response to request needed by (mm/dd/yyyy):
Presentation Topics and Format
Type of Presentation:
--None--
General Educational Session
Informal Meeting
Keynote
Panel Discussion
Other
Please specify:
Will slides be required for the presentation?
--None--
Yes
No
Slide deadline:
Expected attendance at presentation (
*
):
What topics will the requested speaker be discussing (Maxium 500 characters)(
*
)?
Please provide a link to the event agenda(
*
).
(If you do not have an online agenda please email the agenda to
Nancy.Szemraj@hhs.gov
. Requests without agendas will not be considered.)
Event Information
Full Name of the Event (No Acronym)(
*
):
Event or Organization URL (
*
):
Event Background (Maxium 500 characters)(
*
):
Event Expected Attendance (
*
):
Event Attendee Background (check all that apply)(
*
):
--None--
Providers (i.e., physicians, nurses, etc.)
Patients
Vendors
Government Health IT
CIO's/CMIO's
Consumers
Other
Please Specify (Maxium 500 characters):
Other confirmed Speakers at this Event (
*
):
--None--
Yes
No
Please list (Maxium 500 characters):
Will Media be present at the Event?
--None--
Yes
No
Please list all Media invited (Maxium 500 characters):
ONC Spoken at event in past year?
--None--
Yes
No
Please specify ONC speakers and the dates they attended (Maxium 500 characters):
Event Location
Multiple venue locations for this event?:
--None--
Yes
No
List multiple venues:
ONC remote participation available?:
--None--
Yes
No
Venue Name (
*
):
Address Line 1 (
*
):
Address Line 2:
Country (
*
):
State (
*
):
City (
*
):
Postal/Zip Code (
*
):
Event Host Information
Organization Name (No Acronym) (
*
):
Organization URL (
*
):
Type of Organization: (
*
)
--Select--
Academy Entity
Association
Community Health Center Clinic
Consulting or Law Firm
Federal Government
Long Term Care Facility
State Government
Hospital, Multi-Hospital System, Integrated Delivery System
Public Health Facility
Physician Organization
Vendor
Not for Profit
Other
Please Specify Other Organization type:
Organization Facebook Page:
Organization Twitter Handle:
URL of Recent Host Organization's News and Media Coverage (google news search of Organization is fine):
Does this event have any co-sponsors?
--None--
Yes
No
Please Specify Event Co-Sponsors:
Requestor Contact Information
Title
First Name (
*
):
Last Name (
*
):
Email (
*
):
Office Phone (
*
):
Cell Phone:
