DHS Office of the Secretary — External Event Request, F-02903 (06/2022)

Introduction

Thank you for contacting the Department of Health Services Office of the Secretary. Please complete this form in its entirety so we are able to get a sense of the type of engagement you are requesting. Someone from our Office will be in touch in the next few days to confirm receipt and follow up on any specific details as needed.

1. Choose the type of engagement you are requesting. *This question is required.

Please enter an 'other' value for this selection.

Please share a bit about the format of the event (for example, whether you are seeking formal remarks, a question and answer session, both, etc.). *This question is required.

2. What is the anticipated or requested date and time of this event/meeting? *This question is required. If there is not a set date/time, please indicate a preferred date or timeframe.

3. Are you requesting the presence of a specific member of the Office of the Secretary leadership team? *This question is required.

Indicate whose presence you are requesting. *This question is required.

Secretary Kirsten L. Johnson
Deputy Secretary Debra K. Standridge
Assistant Deputy Secretary Sarah E. Valencia

4. Tell us a bit about yourself. *This question is required.

First Name *This question is required.

Last Name *This question is required.

Title *This question is required.

Organization Name *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required. Include area code, using the following format: 999-999-9999