CCPDAP speaker request

SPEAKER AND PUBLIC ENGAGEMENT REQUEST FORM

An important part of the Consortium’s mission involves public engagement. We welcome the opportunity to share Colorado state updates about prescription drug misuse and prevention, build statewide capacity, and engage with national, state, and local partners. We aim to engage with communities throughout the 64 counties in Colorado. There is no charge for a speaker.

To help us make the most informed decision about your request for a Consortium representative to speak at your event, please fill out the following questionnaire. We’ll get back in touch with you shortly.

Primary Contact Name*

First Name

Last Name

Email*

Phone*

Organization*

Speaking Activity Requested*

In-person presentation Virtual Flexible Keynote Panel Opening or closing remarks

Other:

What topics are you interested in?*

State of the State: The Opioid Crisis and Colorado's Response Naloxone Training for end users (this does not incl. CPR) Naloxone Training to train others (facilitation guide provided) Best Practices in Treatment and Recovery Legislative Update

NOTE: If you would like to organize a provider education event, please contact provider education program manager Jessica Eaddy at Jessica.Eaddy@cuanschutz.edu

When is your event? (Date and time of day)*

Please tell us about your event*

What is the size of the expected audience?*

Event Address

Address Line 1

Address Line 2

City

State

ZIP Code

OPTIONAL INFORMATION

Will media be in attendance?

Yes No Not sure

Is there any other information that you feel the speaker should know regarding this request?