Speaker request form - Page 1 of 3 - NHS England

4. If any further information relating to this event is available online - eg downloadable agenda or programme, website, social media, etc - please add details below:

5. What type of session would you like the speaker to participate in?

Deliver a speech Join a panel Join a roundtable discussion Other (specify below)

6. Please give the session start and end times

Session start time (hh:mm)

Session end time (hh:mm)

For panel sessions, estimated speaker contribution time

7. What is the title of the session? (as it will appear on the agenda, if known)

8. Please give some detail here on the areas you would like the speaker to cover during the session

10. Have you contacted anyone at NHS England or NHS Improvement about the event/session before now? If so, please let us know who:

11. Please list below the speakers who have been invited to participate; please split these up by those who have confirmed their participation and who have not

Confirmed speakers

Invited speakers yet to confirm

12. Please give an estimate of the audience numbers - both for the event as a whole, and, if different, for the particular session

Audience numbers (event)

Session audience (if different)

13. From the list below, please select which group will make up most of the audience the requested speaker will address:

Chairs, chief executives, accountable officers (etc) Finance directors HR / workforce leads Other senior leaders (eg chief operating officers, deputy chief executives, improvement directors) Nurses and/or midwives Other clinicians Patients / members of the public Commissioners Other / none of the above (please give an estimate of audience background below)

14. Will any journalists/media be at the event? If so, please give details

15. Please give your name and contact details below:

Your name (Required)

Email address (Required)

Telephone number (Required)

Organisation (Required)

16. If you have any other information you would like to provide on this event, the specific session, our speaker, or you or your organisation, please add it here: