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An Official
Pennsylvania
Government Website
Department of Health
Speaking Request Form
Event Information
The Pennsylvania Department of Health (DOH) is in receipt of your request for a representative of the Department to participate in your conference/meeting. Please note that speaking requests are processed on a weekly basis, so please provide the requested information within 48 hours of receiving this form.
Required fields are marked with an asterisk.(*)
Name of Organization
*
Date(s) and Time of Event
*
Address Line 1
*
Address Line 2
*
City
*
State
Please select an option
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Zip Code
*
Parking Information
*
Name and Brief Description of Event
*
Will this be a CME event?
Will this be a CME event?
No
Will this be a CME event?
Yes
If yes when will the presentation be expected to be sent to organizers
*
Organization’s Point of Contact (POC)
First Name
*
Last Name
*
Title
*
Work Phone (XXX-XXX-XXXX)
*
Cell Phone (XXX-XXX-XXXX)
*
Email Address
*
*
Have you extended this speaking request to any other Pennsylvanian government staff?
Have you extended this speaking request to any other Pennsylvanian government staff?
No
Have you extended this speaking request to any other Pennsylvanian government staff?
Yes
If yes, please indicate names of anyone else you have asked to speak, including those who accepted,
*
Please list any dignitaries in attendance
*
Please list any district legislators in attendance
*
Speech Topic/Stage Set Up
Proposed Topic for Speech
*
Speech Format
*
Length of Speech Time Requested?
*
Will Question and Answer (Q & A) session follow?
Will Question and Answer (Q & A) session follow?
No
Will Question and Answer (Q & A) session follow?
Yes
If yes indicate length of speech and length of Question and Answer session
*
Stage Set Up
Is a PowerPoint presentation appropriate?
Is a PowerPoint presentation appropriate?
No
Is a PowerPoint presentation appropriate?
Yes
If so, will setup be provided?
If so, will setup be provided?
No
If so, will setup be provided?
Yes
Do you require the slides prior to the event?
Do you require the slides prior to the event?
No
Do you require the slides prior to the event?
Yes
Will there be a podium?
Will there be a podium?
No
Will there be a podium?
Yes
Is there a screen to see the slides from the presenting area/stage?
*
What kind of microphone will be provided?
*
Media Information
Audience Profile (ie, public, academia, business group)?
*
Expected Number Attendees?
*
Is this event open or closed to the media?
Is this event open or closed to the media?
No
Is this event open or closed to the media?
Yes
Will there be a request for the Speaker to address media before or after the event?
Will there be a request for the Speaker to address media before or after the event?
No
Will there be a request for the Speaker to address media before or after the event?
Yes
If yes, please provide additional details
*
If media is invited will you be advertising prior to the event? What media outlets will be utilized?
*
Executive Order 2023-04 – Executive Branch Employee Gift Ban
Prohibits Executive Branch employees from soliciting or accepting cash or cash equivalent; a gift or other item of more than nominal or de minimis value; admission to a recreational event; a personal loan; or a personal or professional service in connection with their employment.
Read more about the
updated gift ban
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