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Speaker Request Form

Thank you for inviting a speaker from the New Jersey Health Care Quality Institute (NJHCQI) to participate in your upcoming meeting. To expedite our review of your request, we ask that you complete the following web form.

NOTE: Unfortunately, we cannot accommodate all requests due to limited resources. We will inform you as quickly as possible if a NJHCQI representative can be secured for your event.

Your Contact Information
Name:
Title:
Phone:
Email:

About The Event
Event:
Date
Time:
Location:
Sponsoring Organization:

Organization Category:

Not-For-Profit
For-Profit
Public Agency
New Jersey Based

Type of Organization:
Healthcare Purchaser Provider Hospital Pharmaceuticals	Health Informatics Consumer Health Plan Government
Other, please specify:

Brief Presentation Description:

Presentation Type:

Keynote
Plenary
Panel
Other:

Approximate Number of Attendees:

Attendee Classification:
Employers Physicians Hospital Executives Pharmacists Academics	Health Informatics Consumers Health Plan Executives Benefits Consultants IT Professionals
Other, please specify:

Expenses Covered:

Airfare
Meals
Lodging
Other:

Are you a member of the New Jersey Health Care Quality Institute?

Yes
No

If not, will you offer an honorarium?

Yes
No

If so, please specify an amount ($1,500 minimum recommended):

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