Form Cms-20041 - Speech Invitation Request Background Information
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
SPEECH INVITATION REQUEST BACKGROUND INFORMATION
Event Sponsor
Organization’s Contact Name
Telephone Number
Organization’s Contact E-Mail
Fax Number
Title of Event
Date
Location of Event
Time
Event Format (keynote / panel)
MESSAGE / TOPIC
Total Length of Speech
Is Q&A Required
If “yes,” how long
Yes
No
Describe Audience
Number of Attendees Event Open to Public Event Open to Press
Yes
No
Yes
No
SPECIAL NOTES
Form CMS-20041 (12/05) EF 12/2005
OEA Speech Request Team • Phone: 202.205.6306 • Fax: 202.690.7159 • E-mail: OAspeechrequest@cms.hhs.gov
Form CMS-20004 (12/02)
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Parent category: Medical