Speaker Request

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Speaker Request

Thank you for your interest in having Pulse Center for Patient Safety Education & Advocacy present to your community, association, school, colleagues or family. Please complete the following form to be sure all details are recorded accurately. When done, e-mail icorina@PulseCenterforPatientSafety.org or call (516) 579-4711 to let us know it is complete and allow a day for us to get back to you. For healthcare professionals please call about fees. The program can not be confirmed until you speak to someone at the organization and all information is complete.

Thank you!

Today's date

YYYY

Name of person completing this form

Phone number of person completing this form

E-mail of person completing this form

If this is for a group or organization, what is the name of the group or organization?

How did you learn about Pulse CPSEA? Who should we thank?

Date of program

YYYY

Is date / time flexible? Comment welcome

Time of program and length of time requested to speak. Time for Questions?

Name / title of program

What is the Topic You are Requesting?

Patient Safety and The Patient and Families Role

Patient Safety and Critical Communication

The Health Care Equality Project www.HealthCareEquality.org

The Elephant in the Room, Meeting and Greeting Someone who is Transgender

Teens and Patient Empowerment - The "I" Patient, Informed and Involved (for middle school through 20 years old)

TakeCHARGE 5 Steps for Safer Health Care for adults www.takecharge.care

TakeCHARGE 5 Steps for Safer Health Care for Youth

TakeCHARGE Ambassador Training (4-hours)

Family Centered Patient Advocacy (6-9hours)

Other:

Is power point suggested?

Yes

It doesn't matter

Clear selection

Address /Location (if it is virtual just put zoom and see next question)

How is presentation expected?

Zoom (Your account)

Zoom (Pulse account)

In person If this is in person, additional information will be sent requesting additional information about travel, parking etc.

Other:

Approximate # in attendance

Who are the planned attendees? The Pulse mission is to educate, advocate for and support patients. For audiences of 50% or more healthcare professionals, please call about fees.

Family Caregivers

Community members general

Healthcare professionals mixed (fee TBD)

Nurses (fee TBD)

Doctors (fee TBD)

Nursing students (fee TBD)

Medical students (fee TBD)

Other:

Do you have a request for specific speaker? If so who are you requesting?

Is there a parking lot or a safe place to park and unload?

There is a parking lot

Street parking

There is metered parking

Other:

Have you spoken to someone already? If so to whom did you speak?

Pulse is a nonprofit organization and a speakers fee or donation is suggested. Can we count on a donation? (Your response will not change the planned presentation)

Please add any additional information that will be helpful to make this program a success

Submit

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