HRSA Speaking Engagement Request Form

The public is invited to request the HRSA Administrator or a liaison to speak at an upcoming event. Please complete the form below in its entirety so that HRSA understands the context of this request.

Please do not use this form for interviews or media-related inquiries. Media-related inquiries need to be submitted via this form.

A minimum of one month’s advanced notice is required for a request to be considered. All communication from HRSA, for both approvals and denials, will be directed to the point of contact listed in the form.

Please note: Submitting a Speaking Engagement Request Form does not guarantee that a HRSA representative will attend the upcoming event.

For questions related to this speaking engagement form, please reach out to: HRSASpeakingRequests@hrsa.gov.

Required fields are marked with an asterisk (*).

Please enter 'N/A' in any field where the information is not applicable.

Contact Information

Name of organization(s) requesting HRSA administrator*

Title*

First name*

Last name*

Email*

Phone*

Event Information

Event name*

Entire event start date*

Entire event end date*

When do you need a final commitment by HRSA?*

Is this event in-person, virtual, or hybrid?*

Meeting/event URL (registration link/informational webpage). If not available, comment “N/A” in the box.*

Address, city, state, zip code. If event is virtual, comment “N/A” in the box.*

Brief description of event*

Event details

Brief description of sponsoring organization(s)*

Website for sponsoring organization. If not available, comment “N/A” in the box.*

Who is the audience for this event?*

Expected number of attendees*

Must have at least 2 attendees

Is This Event Open to The Public or Invitation Only?*

Is the press invited to the event?*

Is there a conference hotel associated with this event?*

Speaker Invitation Details

For what date(s) and time(s) are you requesting a HRSA speaker?

HRSA speaker request start*

HRSA speaker request end*

Is there a cost for speakers, and if so, how much? If there is no cost, comment "N/A" in the box.*

If the HRSA administrator cannot participate in the event, is your organization interested in an alternate HRSA speaker? If you’d like a specific alternate HRSA speaker, please list in the next question.*

Please list any specific HRSA staff you’d be interested in as an alternative speaker*

Have you extended this speaking request to any other HRSA staff and/or HHS staff? If not, comment "N/A" in the box.*

Speech format (For example: keynote, panel, opening remarks, etc.) Please include details on time allotment in the text box, including question and answer portion if relevant.*

What topics would you like HRSA to speak on?*

Is a draft agenda currently available? If yes, please email the draft agenda to the HRSA Speaker Request inbox at HRSASpeakingRequests@hrsa.gov.*

Are other federal government employees, congressional members, or other VIP officials expected to attend? If yes, please specify below. If not, comment "N/A" in the box.*

Have you had other HRSA presenters at this event in the past? If yes, who participated?*

Comments: Please include any other relevant details not included above or any questions below.

Form Approved
OMB No. 0906-0104
Exp. 11/30/2027
Public Burden Statement: The purpose of this form is for members of the public to request the Administrator or their liaison at a speaking engagement. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0104 and it is valid until 11/30/2027. This information collection is voluntary. Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

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HRSA Speaking Engagement Request Form

Contact Information

Event Information

Event details

Speaker Invitation Details