IAHCSMM Speaker Request Form

Chapter Name:

Date(s) of Event:
Location of Event:

Contact Person Name:
Contact Person Email:
Contact Person Phone Number:

Requested Topic: (For a list of topics; contact IAHCSMM):
Date of Requested Presentation:
Time of Requested Presentation:
Length of Presentation: (Presentations are 1.25 hours in length):
Expected Number of Attendees:

What is your Target Audience (Check all that apply)
CS Technicians CS Managers OR Infection Control Other

Briefly describe how this program supports IAHCSMM’s Mission:


Will your Chapter sponsor this speaker?	Yes No
Are you seeking sponsorship for this speaker?	Yes No

Has your group requested a speaker from IAHCSMM in the past 2 years?	Yes No

Submitted by:

Speaker Request Form for
Elected Board Members / Educational Director