Speaker Requested: *Surgeon GeneralDeputy Surgeon GeneralDirector of Commissioned Corps HeadquartersWould you be willing to accept a surrogate speaker if the one you have requested is unable to participate? *YESNOName of Inviting Organization / Individual: *Organization Description: *Organization Website:Event Name: *Type of Event: *CommencementGrand RoundsMeetingBriefingConference/SummitReceptionAwards CeremonyRetirementWebinarRoundtableOther (Breakfast, Dinner, Fireside)Event Start: *Event End: *Event Description: *Speaking Date: *Speaking Date Flexible: *YESNOSpeaking Start Time: *Event Time Zone *Is speaking start time flexible?: *YesNoSpeaking Duration: *0 min5 Min10 Min15 Min20 min30 min45 min60 minQ&A Duration: *No Q&A5 Min10 Min15 Min30 MinAddress Type: *Keynote (Plenary Session)Remarks (Welcome, Closing)Fireside ChatPanel DiscussionOtherProposed Speaking Topic(s): *Select all that apply. You may select multiple values by holding down your Ctrl key while selecting.Cancer PreventionClinician BurnoutCOVID-19Emotional Well-BeingHealth and National SecurityMaternal HealthMinority HealthSocial Needs/Social Determinants of Health (SDOH)Substance Misuse/Substance Use Disorder (tobacco/vaping, opioids, marijuana)VaccinationsWomen’s Health (other than maternal)OtherSpeaking Topic Details:Event Venue: *If the event is virtual, enter “n/a” for event location fields.Event Address: *Event City: *Event State: *n/a – event is virtualAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islandsn/a - event is outside of the USAEvent Zip Code: *Event Country: *United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweAre you expecting any distinguished guests at this event? *Are any other HHS officials speaking at this event? *Please provide the names of any registered lobbyists who will be in attendance: *What types of media are invited to the event? *BroadcastPrint and/or WebLocalRegionalNationalLive WebcastMedia Not InvitedAudience Size: *Audience Composition & Proportions: *Event ContactEvent Contact Name: *Event Contact Title: *Event Contact Email: *Event Contact Phone: *Is the inviting organization registered as a lobbyist? *YesNoIs the inviting organization a 501(3)(c)?: *YesNoIs there a fundraising component to this event? *YesNo