Thank you for your interest in having someone from the Office for Civil Rights speak at your event. Please submit this completed form to help us evaluate your speaker request. * Indicates a required field. Requested Subject Area Civil Rights Conscience & Religious Freedom Health Information Privacy OCR Overview Sponsor Information: Sponsoring Organization: Point of Contact Name: Title: Phone #: Ext: Fax: Email: Event Information: Event: Date: City: State: - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Venue: Event Website URL: Type of Event: - Select - Academic Training Bar Association Training Governmental Conference National Conference Plenary Panel State or Local Conference Other Event Type of Audience: Advocacy Organizations Attorneys Civil Rights Agency Consumers Employers / Plan Sponsors Government Human Services Organizations Law Enforcement Medical Associations/Professionals Privacy Officers/Compliance Officers Professional Organizations Religious Organizations Students Other Windows: Control + Click to select multiple items / Mac: Command + Click to select multiple items Other Audience Number of Attendees: Please input numbers only. Requested OCR Presentation: Type - Select - Breakout Breakout Panel Plenary Plenary Panel Other Other Type Please describe what topic(s) you would like the speaker to address: Length of Time: Please input numeric values only. A decimal point can be used for quarter and half hour increments. Requested Materials: Handouts Power Point Presentation Speaker Biography Other None Windows: Control + Click to select multiple items / Mac: Command + Click to select multiple items Type of Audio/Video and IT Provided: Is the event open to the public? Yes No Will this event be recorded, streamed or broadcast? Yes No Is this event open to the media? Yes No Is there a cost to attend? Yes No Cost $ Please input numbers only. Decimal point and comma are allowed. Is there a cost for the OCR Presenter? Yes No Cost $ Please input numbers only. Decimal point and comma are allowed. What is the cost for federal government attendees? Cost $ Please input numbers only. Decimal point and comma are allowed. Date response requested by: Please use the text box below to provide any additional information you wish OCR to know about the event. For example, accommodations needed such as documents in Braille or large print; Section 508 compliant presentations, etc. Attachment(s): Upload Up to eight files can be uploaded. Accepted File Types: .doc, .docx, .pdf, .ppt, pptx, .jpg, .jpeg, .gif, .png (Maximum File Size: 200KB per file) NOTE: Only file type(s) and max size indicated below will be accepted. Everything else will be ignored. Unlimited number of files can be uploaded to this field.2 MB limit.Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, ppt, pptx. Submit
