Request a Speaker • Patient Safety Movement

Your Contact Information
Full Name*
Email Address*
Phone*
Title*
Organization Information
What is the name of the organization that would be hosting this virtual event?*
Please list the degree/program students are pursuing (If Healthcare Professional, please put NA)*
Please list what healthcare related field you are in. (If Student, put NA)*
Organization's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Event Details
Type of presentation*
Which presentation are you interested in*
When are you looking to schedule this presentation?*
What time of day are you looking for this presentation to occur? (Morning, Afternoon, Evening)*
How many attendees do you anticipate for this event?
What level of learner are the attendees as it relates to patient safety? Please select all that apply.
- Novice
- Advanced beginner
- Competent
- Proficient
- Expert
Is there any specific patient safety topic you would like to request that our presenters speak about? *This will taken into account but is not guaranteed
Is there anything you'd like to circulate in advance?
Any additional comments?

Patient Safety Speakers Coalition