This is archived HHS content.

Office for Civil Rights Speaker Request

Submitted by rzuckerman on November 27, 2018 | 10:43 am EST

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

Sponsoring Organization: *

Point of Contact Name: *

Title:

Phone #: *

Ext:

Fax:

Email: *

Event Information:

Event: *

Date: *

Year

Month

Day

City: *

State: *

Venue:

Event Website URL:

Type of Event: *

Type of Audience: *

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Other Audience *

Number of Attendees: *

Please input numbers only.

Requested OCR Presentation:

Type *

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: *

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

Will this event be recorded, streamed or broadcast? *

Yes

Is this event open to the media? *

Yes

Is there a cost to attend? *

Yes

Cost $ *

Please input numbers only. Decimal point and comma are allowed.

Is there a cost for the OCR Presenter? *

Yes

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: *

Year

Month

Day

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):

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.

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Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx.

This is archived HHS content.

Office for Civil Rights Speaker Request

Event Information:

Requested OCR Presentation:

Connect With OCR

Office for Civil Rights Headquarters

Office for Civil Rights Speaker Request

Sponsor Information:

Event Information:

Requested OCR Presentation: