Grand Rounds Speaker Bureau Request Form

Hopkins Grand Rounds Speakers Bureau Request Form

Fill out this form to request a speaker.

REQUESTOR INFORMATION

Hospital Name «

Hospital Address

City

State

Zip Code

Contact Name

Contact Address

City

State

Zip Code

Contact Phone Number

Contact Fax Number

Contact E-mail «

Location of where lecture is held within your hospital

Do you provide an honorarium?

Yes No

If so, what is the average amount provided?

What time are Grand Rounds held at your hospital?

Speaker

HOPKINS SPEAKER BEING REQUESTED

In the fields below, please request a topic and 3 available dates for each topic. Up to five topics can be requested with 3 choices of dates for each topic.

Topic 1

Preferred Date

Alternate Date

Questions or Concerns

Topic 2

Preferred Date

Alternate Date

Questions or Concerns

Topic 3

Preferred Date

Alternate Date

Questions or Concerns

Fields marked with « are required.

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Grand Rounds Speaker Bureau Request Form