Speakers Bureau Request Form
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Page 1
Organization Information:
Organization Name
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Address 1
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Address 2
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City
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State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
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Organization Website URL
248 characters left.
Sponsor Name
255 characters left.
Page 2
Primary Contact Information:
Salutation
Please select...
Adm.
BG
Br.
Capt.
Chap
Cmdr.
Col.
Cpl.
CSM
Dr.
Fr.
Gen.
LCpl.
LPN
Lt.
Lt.Col
Lt.Gen
LtCmdr
Maj.
MajGen
Miss
MP
Mr.
Mrs.
Ms.
MSgt.
Mx.
NP
Prof.
RDML
Rev.
RN
Sgt.
Sr.
SSgt.
First Name
100 characters left.
Last Name
100 characters left.
Email
255 characters left.
Phone
Title
255 characters left.
The Primary Contact is not the same person that will sign off on the Speakers Bureau Engagement Contract
Contract Sign off Contact Information:
Salutation
Please select...
Adm.
BG
Br.
Capt.
Chap
Cmdr.
Col.
Cpl.
CSM
Dr.
Fr.
GEN
LCpl.
LPN
Lt.
Lt.Col
Lt.Gen
LtCmdr
Maj.
MajGen
Miss
MP
Mr.
Mrs.
Ms.
MSgt.
Mx.
NP
Prof.
RDML
Rev.
RN
Sgt.
Sr.
SSgt.
First Name
100 characters left.
Last Name
100 characters left.
Email
255 characters left.
Phone
Title
255 characters left.
Page 3
Meeting Information:
Meeting Title
255 characters left.
Type of Meeting
In Person Presentation
Online Presentation
Requested Category
Please select...
Accreditation
Care Delivery
Certification
Data and Information
Measures
Other
Safety Events and Risk Management
Standards
Workforce and Workplace
Requested Sub-Category
Please select...
Ambulatory Health Care (Bureau of Primary Health Care, Imaging Centers, Office-Based Surgery, Sleep Centers, Surgery Centers, Urgent Care Centers)
Behavioral Health Care
Home Care Agencies
Hospitals and Critical Access Hospitals
Laboratory Services
Nursing Care Center
Survey Process
Care Delivery System Transformation
Patient-Centered Care
Patient-Centered Communications
Value-based Payment
Advanced Perinatal Care
Behavioral Health Care
Disease-Specific Care (Heart, LVRS, Stroke, VAD)
Primary Care Medical Home
Responsible Use of Health Data
Review Process
Sustainable Health Care
AI Governance in Quality Measures
Artificial Intelligence
Responsible Use of Health Data
Health Care Quality
Heart Failure and Stroke
Maternal Health Electronic Clinical Quality Measurement (eCQMs)
Patient Reported Outcome
Payer Uses of Measures
High Reliability
Human Factors and Systems Thinking
Proactive Risk Assessment
Sentinel Events and Root Cause Analysis
Suicide Prevention in Healthcare
Environment of Care/Life Safety/Emergency Management
Environmental Sustainability/Decarbonization in Health Care
Healthcare Equity/Healthcare Disparities
Infection Control and Prevention
Medication Management
National Patient Safety Goals
Second Victim
Volunteers
Workforce Safety & Well-being
Workplace Violence Prevention
Other Category
255 characters left.
Title of Presentation
255 characters left.
Deadline for securing a speaker
Meeting Date
Presentation Starting Time
Please select...
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
Presentation Ending Time
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8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
Contact Phone on Meeting Day
Would you like to provide an alternate meeting time?
No
Yes
Alternate Meeting Date
Alternate Presentation Starting Time
Please select...
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
Alternate Presentation Ending Time
Please select...
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
Time Zone
Please select...
Atlantic
Eastern
Central
Mountain
Pacific
Hawaii-Aleutian
Meeting Attire
Please select...
Business
Business Casual
Casual
If you have a preferred speaker(s), enter their name(s) here:
255 characters left.
Audience Size
6 characters left.
Audience Composition
255 characters left.
A/V Equipment Available
Handheld Pointer
Laptop
Podium
Projector and Screen
Smart Board
Wireless Microphone
Page 4
Meeting Venue:
Is the meeting venue held at the organization address or a different venue?
Organization Address
Different Venue Address
Venue Name
Address 1
Address 2
City
State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
10 characters left.
Online Presentation Venue:
Please select the online presentation venue type.
Zoom
Teams
Webinar
Other
Please enter an online presentation venue type of other.
255 characters left.
Page 5
Recommended Lodging & Travel
Lodging same as meeting venue
Name of Hotel
Address 1
Address 2
City
State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
10 characters left.
Phone
Recommended Ground Transportation
Please select...
Car Rental
Hotel Shuttle
Ride-Sharing App (Lyft/Uber)
Other
Recommended Ground Transportation Other
255 characters left.
Closest Airport
Page 6
Additional Comments
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