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DPH Speaker Request, F-02859 (08/2021)

Thank you for contacting the Division of Public Health (DPH) with your request. We would like to assist you by providing the appropriate individual from our division to participate in your event, if possible. Organizations requesting a speaker from our division for events such as a conference, meeting, panel discussion, or similar events must fill out the form in its entirety. If this is a rush request, please be sure to indicate this in the additional information field at the bottom of the survey. If you are a member of the press, please send your inquiry or interview request to DHSMedia@dhs.wisconsin.gov.

1. Choose the type of engagement you are requesting.

2. What is the purpose of the speaking engagement?

3. What topic (or topics) do you want the speaker to discuss?

4. What is the date and time of the speaking engagement? (If there is not a set date/time, please indicate a preferred date or timeframe.)

5. What is the name of the organization?

6. Provide the website address, if applicable. Be sure to include the entire URL, beginning with "http://" or "https://."

7. Provide a few sentences about the organization.

8. Who is the targeted/expected audience?

9. Describe the venue type.

10. What is the speaking engagement location (include address and room number or virtual platform)?

11. Provide parking location for the speaking engagement.

12. Length of speaking time (indicate using hours and/or minutes):

13. Indicate the type of speaking engagement (select all that pertain to this request).

14. Available equipment:

Microphone
Teleprompter
Podium

15. Contact information:

First Name
Last Name
Email Address
Phone Number

16. Additional information you would like to provide regarding the speaking engagement? You may also use this space to request a specific staff member.