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Request a Public Health Speaker
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1.
Scheduler's Contact Information
(Required.)
Name
Organization or Group Name
Email Contact
Phone Contact
*
2.
Type of presentation
(Required.)
Business
Community
School
Government
Other
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3.
Date requested
(Required.)
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4.
Time requested
(Required.)
*
5.
Length requested
(Required.)
20 minutes or less
30 minutes
1 hour
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6.
Topic(s) requested
(Required.)
COVID vaccines/updates
Long/post-COVID
Delta variant
COVID prevention (e.g. infection control in the workplace)
COVID + Policy (e.g. city councils, Tribal councils, municipalities)
COVID + Children (e.g. schools)
Public Health Topics
Other (please specify)
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7.
Requested speaker:
(Required.)
Health Care Provider
Chief Medical Officer
8.
Type of Program
Online (e.g. zoom, radio)
In-Person (e.g. events, town halls, community councils)
Pre-recorded
Other (please specify)
9.
If online, what platform are you using? Please share the link.
10.
Expected Number of Participants
Less than 10
20-30
50+
100+
Other
11.
Is this event local or national?
12.
Please tell us more about your goals for the speaker so they can best meet the needs of your organization/group.