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Contact Email*

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Event Overview

Event Title:*

Name of Organization Hosting Event:*

Description of Organization:*

Event Location:*

Event date:*

Event start time:*

End Time:*

Director's participation requested start time*

Director's participation requested end time*

Please Select Time Zone*

Contact Person

Contact Person:*

Contact Office Phone:*

Contact Cell Number:*

Contact Email:*

Event Details

Is the event flexible?*

What is the purpose of this event?:*

Proposed role of Director?*

If the Director is unable to attend, would you be interested in hosting another CDC speaker?*

If the Director is unable to attend in person, would joining by video teleconference be an option?*

If the Director is unable to attend in person or by video teleconference, would a pre-recorded message be an option?*

Event Link:*

Event Link for Director's assistants, if different:*

Presentation Details

Topic of Presentation:*

Type of Presentation:*

If panel, please provide a list of other invited and/or confirmed panelists.*

Other Speakers from CDC:*

Length of Presentation:*

PowerPoint Requested?*

If the Director has a last-minute urgent schedule changes, is an alternate speaker acceptable?*

What is the Director's requested participation time?*

Speaking Time:*

Q&A:*

Listening to Discussion:*

Other:*

Remarks

What specific public health topic(s) would you like the Director to address at this event?*

Audience Size:*

Who will introduce the Director?*

After the Director's presentation, should she turn the "podium" over to someone else? If so, who is that person?*

If there will be Q&A, will topics/questions be available ahead of time? Who will moderate the discussion?*

Are there any other speakers at this event? If so, who?*

Please identify other speakers equal to or higher than the Director's level.*

Please identify any US government officials speaking at or attending this event:*

Please identify any other speakers from CDC requested for this event:*

Is this event open to the public or invite only?*

Will this event be recorded or livestreamed?*

Will the recording be posted on the web for future viewing?*

Will media be present?*

If so, which media outlets will attend?*

Additional Details

Please list any social media accounts that plan to cover the event: *

In your eyes, what would make this event a success?(optional)

If prerecorded remarks are acceptable or requested

Preferred file format:*

Who should receive the finished recording?*

What is the deadline for receiving the recording?*

Does it need to be closed captioned?*

Would you like the Director's name and title shown at the bottom of the screen during the opening of the recording (similarly to how names and titles are shown during news interviews)?*

Additional comments/information: *

* Required field

CDC Director: Speaker Request