Bio Ascend Grand Rounds/Tumor Board Program Request Form

Question Title

* 1. Contact Information

Name

Institution

City, State

Phone number

Email address

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* 2. In what type of setting will this program take place?

Grand rounds

Tumor board

Other (please specify)

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* 3. Please provide the estimated audience breakdown numbers

	Estimated Attendees
Med Onc MDs	Med Onc MDs Estimated Attendees menu
Hem Onc MDs	Hem Onc MDs Estimated Attendees menu
Gyn Onc MDs	Gyn Onc MDs Estimated Attendees menu
Rad Onc MDs	Rad Onc MDs Estimated Attendees menu
Surg Onc MDs	Surg Onc MDs Estimated Attendees menu
Hematopathologists	Hematopathologists Estimated Attendees menu
Pathologists	Pathologists Estimated Attendees menu
Other MDs	Other MDs Estimated Attendees menu
Nurses	Nurses Estimated Attendees menu
Pharmacists	Pharmacists Estimated Attendees menu
Others	Others Estimated Attendees menu

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* 4. Estimated TOTAL attendees

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* 5. Available program dates (or day of the week). Please also list program time.

1st Choice

2nd Choice

3rd Choice

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* 6. Are you able to provide any of the following AV equipment?

Projector screen or TV monitor

Projector

Slide advancer

We are not able to provide any AV equipment

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* 7. May we use an Audience Response System so that participants can respond to polling questions during the program?
A Bio Ascend representative will be onsite to administer this technology. Please note, we will need to use our own laptops to run this software

Yes

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* 8. Can this activity be open to any outside attendees?
We will confirm whether any outside attendees request to observe your program

Yes, outside HCPs may attend

Yes, pharmaceutical industry may attend

No, outside attendees are not permitted

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* 9. Would you like us to provide a catered meal for this activity?

Yes

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* 10. Please provide the address where the program will take place

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 11. What room will this program take place?
(eg. 1st floor conference room)

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* 12. Onsite contact

Name

Phone

Question Title

* 13. Please provide any additional information you would like us to know prior to confirming your program. You can also indicate your preferred speaker(s) here.

Bio Ascend Grand Rounds/Tumor Board Program Request Form

Question Title

* 1. Contact Information

Question Title

* 2. In what type of setting will this program take place?

Question Title

* 3. Please provide the estimated audience breakdown numbers

Question Title

* 4. Estimated TOTAL attendees

Question Title

* 5. Available program dates (or day of the week). Please also list program time.

Question Title

* 6. Are you able to provide any of the following AV equipment?

Question Title

* 7. May we use an Audience Response System so that participants can respond to polling questions during the program?A Bio Ascend representative will be onsite to administer this technology. Please note, we will need to use our own laptops to run this software

Question Title

* 8. Can this activity be open to any outside attendees?We will confirm whether any outside attendees request to observe your program

Question Title

* 9. Would you like us to provide a catered meal for this activity?

Question Title

* 10. Please provide the address where the program will take place

Question Title

* 11. What room will this program take place? (eg. 1st floor conference room)

Question Title

* 12. Onsite contact

Question Title

* 13. Please provide any additional information you would like us to know prior to confirming your program. You can also indicate your preferred speaker(s) here.

* 7. May we use an Audience Response System so that participants can respond to polling questions during the program?
A Bio Ascend representative will be onsite to administer this technology. Please note, we will need to use our own laptops to run this software

* 8. Can this activity be open to any outside attendees?
We will confirm whether any outside attendees request to observe your program

* 11. What room will this program take place?
(eg. 1st floor conference room)