NCCIH Director Speaker Invitation Form

Inviting Organization Information

Name of the inviting organization: (required) ^*

Inviting organization description: (required) ^*

Organization website:

Event sponsor(s): (required) ^*

Name of the individual issuing the invitation: (required) ^*

Is the inviting organization registered as a lobbying organization? (required) ^*

Yes

Is the individual issuing the invitation a registered lobbyist? (required) ^*

Yes

Is the inviting organization a 501(c)(3) organization? (required) ^*

Yes

Is there a fundraising component to this event? (required) ^*

Yes

About the Event

Event name: (required) ^*

Event description (include background and purpose): (required) ^*

(0/125 words)

Event category: (required) ^*

Will an award, certificate, gift, or other item be presented?

Type of remarks:

Proposed speaking topic(s):

List invited and/or confirmed presenters and panelists:

If available, include the URL for the event agenda/program:

Will any materials be needed in advance (e.g., bio, abstract, slides, CME documents)? (required) ^*

Date materials are needed: (required) ^*

Pre-event coordination meeting required? (required) ^*

Yes

Unsure

Timing of Remarks

Speaking date: (required) ^*

Time zone: (required) ^*

Requested duration of remarks: (required) ^*

Q&A duration (if applicable): (required) ^*

Event Location

Is the event virtual or in person? (Virtual/In Person/Both) (required) ^*

Virtual

In Person

Both

If virtual, which platform will you use (e.g., Zoom, Teams, Webex)?

If virtual, will we need to pre-record the presentation?

Event address: (required) ^*

Hotel block/hold/reservation (If room(s) are being held, please provide hotel name, address, contact person/email, confirmation number, and any other important information.)

Audience Details

What is the anticipated audience size? (sum of virtual and in-person audiences) (required) ^*

Audience composition and proportions (e.g., researchers 30%, health care providers 30%, public 40%) (required) ^*

Are any other U.S. Department of Health and Human Services (HHS) officials speaking at this event? If so, who?

Will any registered lobbyists attend the event?

Event Promotion, Ticketing, and Registration Details

Will there be a public livestream? (required) ^*

Yes

Will Dr. Langevin’s presentation be recorded? (required) ^*

Yes

Do you plan to share Dr. Langevin’s slides?

Yes

Unsure

If you plan to promote the event via social media or other channels, please provide social media information (e.g., platforms, hashtags, handles)

Event Point of Contact

Point of contact name: (required) ^*

Point of contact title: (required) ^*

Point of contact email: (required) ^*

Point of contact phone: (required) ^*