Webinar Hosting Request Form

Webinar Information

1. Do you plan to provide CE credits for this webinar? (If so, you will need to contact the IHS Clinical Support Center.)

2. Proposed Date:

3. Alternate Date (if applicable):

4. Select a Start Time: (00:00 AM)

5. Select an End Time: (00:00 PM)

6. Time Zone:

NOTE: Most of Arizona does not observe Daylight Saving Time. From March to November, Arizona (outside of Navajo Nation) is aligned with Pacific time due to Daylight Saving Time. Navajo Nation follows Mountain time year round.

7. Title of Webinar

8. Short Description

9. How Many Attendees do you need space for (i.e. virtual room size)? (Please Select one):

10. Will you need this to be recorded? (Please Select one):

11. Will you need evaluation conducted (post-survey for attendees to complete at the end of the webinar)?:

12. This webinar is (Please Select one):

13. Do you need people to register beforehand or just a direct link to enter the meeting?:

14. Who is your target audience? (check one or more):

Licensed Alcohol and Drug Counselors

Licensed Professional Counselors

Nurses/Nurse Practitioners

Pharmacists

Physician Assistants

Physicians/Psychiatrists

Psychologists

Social Workers

Other (see below)

Other (please specify)

15. Presenter or Organizer Contact Information

Presenter 1 Name/Credentials:

Organization/IHS Department:

Email Address:

Phone Number:

Presenter 2 Name/Credentials:

Organization/IHS Department:

Email Address 2:

Phone Number 2:

16. Comments/Additional Information, or questions?