Speaking Request Form · Starter Portal

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

Zip Code

Parking Information

Name and Brief Description of Event

Will this be a CME event?

NoYes

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?

NoYes

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?

NoYes

If yes indicate length of speech and length of Question and Answer session

Stage Set Up

Is a PowerPoint presentation appropriate?

NoYes

If so, will setup be provided?

NoYes

Do you require the slides prior to the event?

NoYes

Will there be a podium?

NoYes

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?

NoYes

Will there be a request for the Speaker to address media before or after the event?

NoYes

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.

Required fields are marked with an asterisk.(*)

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