Indian Health Service
The Federal Health Program for American Indians and Alaska Natives

Request a Speaker/Meeting

Is this request for a Tribal Delegation Meeting (TDM)?
Yes No

Requestor / Point of Contact Name

Organization Name (Include Description)

Phone

Event Website

Supporting Documents (e.g., event agenda, draft program or speaker list, event flyer/announcement, formal invitation letter, or other relevant materials):

File 1:

File 2:

File 3:

Engagement Title

Event Start Date

Event End Date

Engagement Purpose

Topics and/or Sub-Topics to be Discussed

Site Visit
Grand Opening / Ribbon Cutting
Award Ceremony / Recognition Event
Celebration / Commemorative Event
Other (please specify)

Requested Speaker

Speaking Date (if multiple date event)

Speaker Start Time

Speaker End Time

Format:
In person Virtual

Event Venue Address

Expected Attendance:
1-50
51-100
101-500
500+

Primary audience:
Tribal organization
Urban Indian organization
Federal government
State government
Healthcare providers or systems

Nonprofit or advocacy organizations
Academia
Private sector
Other (please specify)

Speaker Role:
Keynote Address
Speaker / Presenter
Panelist
Moderator / Facilitator
Meeting Participant (active discussion role)
Other (please specify)

Recorded? Yes No

Media Invited? Yes No

Promoted Publicly? Yes No