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COVID-19 Vaccine Speakers Request Survey

COVID-19 Vaccines are being allocated throughout Minnesota. As the state works to bring these vaccines to all communities there is a lot of interest about the Vaccines. This COVID-19 Vaccine speakers program has been created to meet community members where they are at. The goal of this program is to educate community members about COVID-19 vaccines, raise awareness about the benefits of vaccinations, and address common questions and concerns.

Please allow us at least one week to fulfill your request. Please note, we cannot guarantee a speaker will be available. To help facilitate the process, please complete the form below. Someone from the COVID-19 Vaccine Response team will be in touch.

This form is only for COVID-19 Vaccine speaker requests. To request a speaker on COVID-19 that is not about vaccines. Please go to COVID-19 Speaker Request

Status

Needs attention

In progress

Complete

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DateTime

Event Name

* must provide value

Name of host organization

* must provide value

Date of event

* must provide value

M-D-Y

Start time of event (time when staff are needed to present)

* must provide value

End time of event

* must provide value

Is the date or time flexible?

* must provide value

Yes

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List any co-hosts/co-sponsors of the event

* must provide value

First and Last Name

* must provide value

Title

Phone number

* must provide value

Email address

* must provide value

Who is the targeted audience/community for this presentation? (check all that apply)

* must provide value

African American

African Immigrant

American Indian and Tribal Nations

Asian/Pacific Islander

Company Management

Correctional institutions

Doctors/Nurses

Education/Childcare

Employees

Faith Communities

Health care providers

Homeless/Shelters

Latinx/Hispanic

LGBTQ+

Newer Refugees & Immigrants

Non-status immigrants

People with Disabilities

Seasonal/Agricultural Workers

Seniors/Long Term Care Facilities

Youth Engagement

Other, please describe

Describe other audience(s)

* must provide value

Please provide additional details of who the audience will be (examples: age demographics, sector, population, or expand on what was identified above).

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Describe the geographic reach/focus of the event (rural MN, a specific city/county, statewide)

* must provide value

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If not English, what is the preferred language the speaker should give the presentation in?

If a speaker cannot meet this language need, will you provide an interpreter?

* must provide value

Yes

Non-applicable

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Estimated attendance for this event

* must provide value

Is this a virtual event?

* must provide value

Yes

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STOP!

MDH is only providing speakers for virtual events.

What is the format of the event?

* must provide value

Panel discussion

Recorded video message

Presentation

Other, please describe

Describe other format(s)

Should the speaker provide slides?

* must provide value

Yes

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What is the focus of the content you would like the speaker to cover (check all that apply)?

* must provide value

Equity in vaccine distribution

Vaccine outreach and education

Vaccine safety/hesitancy

Specific medical questions about the vaccine

When the communities I serve will be eligible for vaccine

Other, please describe

Describe other focus

Please share any other specific information the requestor would like covered? What is the audience hoping to learn about COVID Vaccines?

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Will questions be gathered and sent ahead of time?

* must provide value

Yes

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Comments

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