cmsgov.secure.force.com
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52.61.132.1
Public Scan
Submitted URL: https://cmsgov.force.com/act/Activityc
Effective URL: https://cmsgov.secure.force.com/act/Activityc
Submission: On October 13 via manual from US — Scanned from DE
Effective URL: https://cmsgov.secure.force.com/act/Activityc
Submission: On October 13 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form class="slds-form" data-aura-rendered-by="273:0"><lightning-messages data-data-rendering-service-uid="86" data-aura-rendered-by="29:0"></lightning-messages>
<h3 class="slds-section-title--divider" data-aura-rendered-by="30:0">Contact Information</h3><br data-aura-rendered-by="32:0"><label for="fname" data-aura-rendered-by="33:0"><abbr title="required" class="slds-required"
data-aura-rendered-by="34:0">* </abbr>Event Point of Contact First Name</label><lightning-input-field data-aura-rendered-by="37:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label
lightning-input_input="" class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-42"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>First Name</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-42" aria-invalid="false" maxlength="250" name="Event_Point_of_Contact_First_Name__c"
required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="38:0"><label for="lname" data-aura-rendered-by="39:0"><abbr title="required" class="slds-required" data-aura-rendered-by="40:0">* </abbr>Event Point of Contact Last
Name</label><lightning-input-field data-aura-rendered-by="43:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-43"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Last Name</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-43" aria-invalid="false" maxlength="250" name="Event_Point_of_Contact_Last_Name__c" required="">
</div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="44:0"><label for="title" data-aura-rendered-by="45:0"><abbr title="required" class="slds-required" data-aura-rendered-by="46:0">* </abbr>Event Point of Contact Title
</label><lightning-input-field data-aura-rendered-by="49:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-44"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Event Point of Contact Title</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-44" aria-invalid="false" maxlength="250" name="Event_Point_of_Contact_Title__c" required="">
</div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="50:0"><label for="email" data-aura-rendered-by="51:0"><abbr title="required" class="slds-required" data-aura-rendered-by="52:0">* </abbr>Event Point of Contact Email
</label><lightning-input-field data-aura-rendered-by="55:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-45"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Email</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-45" aria-invalid="false" inputmode="email" maxlength="80" name="Event_Point_of_Contact_Email__c"
required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="56:0"><label for="phone" data-aura-rendered-by="57:0"><abbr title="required" class="slds-required" data-aura-rendered-by="58:0">* </abbr>Event Point of Contact Work Phone
</label><lightning-input-field data-aura-rendered-by="61:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-46"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Event Point of Contact: Work Phone</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-46" aria-invalid="false" maxlength="40" name="Event_Point_of_Contact_Work_Phone__c" required="">
</div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="62:0">
<h3 class="slds-section-title--divider" data-aura-rendered-by="63:0">Organization Information</h3><br data-aura-rendered-by="65:0"><label for="org" data-aura-rendered-by="66:0"><abbr title="required" class="slds-required"
data-aura-rendered-by="67:0">* </abbr>Name of Organization(s) Requesting CMS Speaker </label><lightning-input-field data-aura-rendered-by="70:0" class="slds-form-element"><lightning-input class="slds-form-element"
lightning-input_input-host=""><label lightning-input_input="" class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-47"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Company</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-47" aria-invalid="false" maxlength="250" name="Company__c" required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="71:0"><label for="prft" data-aura-rendered-by="72:0"><abbr title="required" class="slds-required" data-aura-rendered-by="73:0">* </abbr>Is this a for-profit or non-profit
organization? </label><lightning-input-field data-aura-rendered-by="76:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-74"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>Is
This A Profit Or Non-Profit ?</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-74" type="button" aria-expanded="false" aria-haspopup="listbox" name="Is_This_A_Profit_Or_Non_Profit__c" data-value="--None--"
aria-label="Is This A Profit Or Non-Profit ?, --None--" aria-controls="dropdown-element-74"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-74" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="77:0"><label for="desc" data-aura-rendered-by="78:0"><abbr title="required" class="slds-required" data-aura-rendered-by="79:0">* </abbr>Brief
Description of Sponsoring Organization(s)</label><lightning-input-field data-aura-rendered-by="82:0" class="slds-form-element"><lightning-textarea class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea=""
class="slds-form-element__label slds-assistive-text" for="input-48"><abbr lightning-textarea_textarea="" class="slds-required" title="required">*</abbr>Activity Objective</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-48" name="Description__c" maxlength="1000" required=""></textarea>
</div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="83:0"><label for="website" data-aura-rendered-by="84:0"><abbr title="required" class="slds-required" data-aura-rendered-by="85:0">* </abbr>Website for Sponsoring Organization
</label><lightning-input-field data-aura-rendered-by="88:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-49"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>CMS Activity Website and Link</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-49" aria-invalid="false" maxlength="255" name="CMS_Activity_Website_and_Link__c" required="">
</div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="89:0">
<h3 class="slds-section-title--divider" data-aura-rendered-by="90:0">Event Details</h3><br data-aura-rendered-by="92:0"><label for="eventname" data-aura-rendered-by="93:0"><abbr title="required" class="slds-required" data-aura-rendered-by="94:0">*
</abbr>Event Name </label><lightning-input-field data-aura-rendered-by="97:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-50"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>CMS Activity Name</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-50" aria-invalid="false" maxlength="80" name="Name" required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="98:0"><label for="stdate" data-aura-rendered-by="99:0"><abbr title="required" class="slds-required" data-aura-rendered-by="100:0">* </abbr>Event Start Date
</label><lightning-input-field data-aura-rendered-by="103:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><lightning-datepicker lightning-input_input="">
<div class="slds-dropdown-trigger slds-dropdown-trigger_click slds-size_1-of-1" role="group"><label class="slds-form-element__label slds-assistive-text" for="input-52"><abbr class="slds-required" title="required">*</abbr>Event
Start(new)</label>
<div class="slds-form-element__control slds-input-has-icon slds-input-has-icon_right"><input class="slds-input" type="text" id="input-52" name="E_Start_Date__c" required="" autocomplete="off"><lightning-button-icon
class="slds-input__icon slds-input__icon_right"><button class="slds-button slds-button_icon slds-button_icon-bare" title="Select a date for Event Start(new)" type="button"><lightning-primitive-icon><svg class="slds-button__icon"
focusable="false" data-key="event" aria-hidden="true" viewBox="0 0 52 52">
<g>
<g>
<path
d="M46.5 20h-41c-.8 0-1.5.7-1.5 1.5V46c0 2.2 1.8 4 4 4h36c2.2 0 4-1.8 4-4V21.5c0-.8-.7-1.5-1.5-1.5zM19 42c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm0-10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm10 10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm0-10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm10 10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm0-10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zM44 7h-5V5c0-1.6-1.3-3-3-3-1.6 0-3 1.3-3 3v2H19V5c0-1.6-1.3-3-3-3-1.6 0-3 1.3-3 3v2H8c-2.2 0-4 1.8-4 4v2.5c0 .8.7 1.5 1.5 1.5h41c.8 0 1.5-.7 1.5-1.5V11c0-2.2-1.8-4-4-4z">
</path>
</g>
</g>
</svg></lightning-primitive-icon><span class="slds-assistive-text">Select a date for Event Start(new)</span></button></lightning-button-icon></div>
</div>
</lightning-datepicker></lightning-input></lightning-input-field><br data-aura-rendered-by="104:0"><label for="endate" data-aura-rendered-by="105:0"><abbr title="required" class="slds-required" data-aura-rendered-by="106:0">* </abbr>Event End
Date </label><lightning-input-field data-aura-rendered-by="109:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><lightning-datepicker lightning-input_input="">
<div class="slds-dropdown-trigger slds-dropdown-trigger_click slds-size_1-of-1" role="group"><label class="slds-form-element__label slds-assistive-text" for="input-56"><abbr class="slds-required" title="required">*</abbr>Event
End(New)</label>
<div class="slds-form-element__control slds-input-has-icon slds-input-has-icon_right"><input class="slds-input" type="text" id="input-56" name="E_End_Date__c" required="" autocomplete="off"><lightning-button-icon
class="slds-input__icon slds-input__icon_right"><button class="slds-button slds-button_icon slds-button_icon-bare" title="Select a date for Event End(New)" type="button"><lightning-primitive-icon><svg class="slds-button__icon"
focusable="false" data-key="event" aria-hidden="true" viewBox="0 0 52 52">
<g>
<g>
<path
d="M46.5 20h-41c-.8 0-1.5.7-1.5 1.5V46c0 2.2 1.8 4 4 4h36c2.2 0 4-1.8 4-4V21.5c0-.8-.7-1.5-1.5-1.5zM19 42c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm0-10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm10 10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm0-10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm10 10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zm0-10c0 .6-.4 1-1 1h-4c-.6 0-1-.4-1-1v-4c0-.6.4-1 1-1h4c.6 0 1 .4 1 1v4zM44 7h-5V5c0-1.6-1.3-3-3-3-1.6 0-3 1.3-3 3v2H19V5c0-1.6-1.3-3-3-3-1.6 0-3 1.3-3 3v2H8c-2.2 0-4 1.8-4 4v2.5c0 .8.7 1.5 1.5 1.5h41c.8 0 1.5-.7 1.5-1.5V11c0-2.2-1.8-4-4-4z">
</path>
</g>
</g>
</svg></lightning-primitive-icon><span class="slds-assistive-text">Select a date for Event End(New)</span></button></lightning-button-icon></div>
</div>
</lightning-datepicker></lightning-input></lightning-input-field><br data-aura-rendered-by="110:0"><label for="sttime" data-aura-rendered-by="111:0"><abbr title="required" class="slds-required" data-aura-rendered-by="112:0">* </abbr>Event Start
Time</label><lightning-input-field data-aura-rendered-by="115:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-79"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>Event
Start Time</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-79" type="button" aria-expanded="false" aria-haspopup="listbox" name="Event_Start_Timepk__c" data-value="--None--"
aria-label="Event Start Time, --None--" aria-controls="dropdown-element-79"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-79" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="116:0"><label for="endtime" data-aura-rendered-by="117:0"><abbr title="required" class="slds-required" data-aura-rendered-by="118:0">* </abbr>Event End
Time</label><lightning-input-field data-aura-rendered-by="121:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-84"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>Event
End Time</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-84" type="button" aria-expanded="false" aria-haspopup="listbox" name="Event_End_Timepk__c" data-value="--None--"
aria-label="Event End Time, --None--" aria-controls="dropdown-element-84"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-84" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="122:0"><label for="timezone" data-aura-rendered-by="123:0"><abbr title="required" class="slds-required" data-aura-rendered-by="124:0">* </abbr>Event
Time Zone</label><lightning-input-field data-aura-rendered-by="127:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-89"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>Event
Time Zone</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-89" type="button" aria-expanded="false" aria-haspopup="listbox" name="Event_Time_Zone__c" data-value="--None--"
aria-label="Event Time Zone, --None--" aria-controls="dropdown-element-89"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-89" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="128:0"><label for="mdays" data-aura-rendered-by="129:0"><abbr title="required" class="slds-required" data-aura-rendered-by="130:0">*</abbr>If event
spans multiple days, what specific date and time are you requesting a CMS speaker? </label><lightning-input-field data-aura-rendered-by="133:0" class="slds-form-element"><lightning-input class="slds-form-element"
lightning-input_input-host=""><label lightning-input_input="" class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-59"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>For what date(s) and
time(s)</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-59" aria-invalid="false" maxlength="250" name="For_what_date_s_and_time_s__c" required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="134:0"><label for="public" data-aura-rendered-by="135:0"><abbr title="required" class="slds-required" data-aura-rendered-by="136:0">*</abbr>Is the event open to the public, open
to members, or by invitation only? </label><lightning-input-field data-aura-rendered-by="139:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist=""
class="slds-form-element" lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-94"><abbr lightning-combobox_combobox="" class="slds-required"
title="required">*</abbr>Open To The Public Or Invitation Only?</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-94" type="button" aria-expanded="false" aria-haspopup="listbox" name="Open_To_The_Public_Or_Invitation_Only__c" data-value="--None--"
aria-label="Open To The Public Or Invitation Only?, --None--" aria-controls="dropdown-element-94"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-94" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="140:0"><label for="medium" data-aura-rendered-by="141:0"><abbr title="required" class="slds-required" data-aura-rendered-by="142:0">*</abbr>Requested
Presentation Medium </label><lightning-input-field data-aura-rendered-by="145:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-99"><abbr lightning-combobox_combobox="" class="slds-required"
title="required">*</abbr>Requested Presentation Medium</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-99" type="button" aria-expanded="false" aria-haspopup="listbox" name="Requested_Presentation_Medium__c" data-value="--None--"
aria-label="Requested Presentation Medium, --None--" aria-controls="dropdown-element-99"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-99" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="146:0"><label for="loc" data-aura-rendered-by="147:0"><abbr title="required" class="slds-required" data-aura-rendered-by="148:0">*</abbr>Event Location
(e.g., name of hotel or conference center; if virtual, please enter intended web platform) </label><lightning-input-field data-aura-rendered-by="151:0" class="slds-form-element"><lightning-input class="slds-form-element"
lightning-input_input-host=""><label lightning-input_input="" class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-60"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Location</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-60" aria-invalid="false" maxlength="250" name="Location__c" required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="152:0"><label for="add" data-aura-rendered-by="153:0"><abbr title="required" class="slds-required" data-aura-rendered-by="154:0">* </abbr>Event Address (if virtual, please enter
n/a) </label><lightning-input-field data-aura-rendered-by="157:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-61"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Address</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-61" aria-invalid="false" maxlength="100" name="Address__c" required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="158:0"><label for="zip" data-aura-rendered-by="159:0"><abbr title="required" class="slds-required" data-aura-rendered-by="160:0">*</abbr>Event Zip Code (If virtual, please enter
your Organization's zip code) </label><lightning-input-field data-aura-rendered-by="163:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-62"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Zip Code</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-62" aria-invalid="false" maxlength="10" name="Zip_Code__c" required=""></div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="164:0"><label for="format" data-aura-rendered-by="165:0"><abbr title="required" class="slds-required" data-aura-rendered-by="166:0">*</abbr>Requested Presentation Format
</label><lightning-input-field data-aura-rendered-by="169:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-104"><abbr lightning-combobox_combobox="" class="slds-required"
title="required">*</abbr>Requested Presentation Format</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-104" type="button" aria-expanded="false" aria-haspopup="listbox" name="Requested_Presentation_Format__c" data-value="--None--"
aria-label="Requested Presentation Format, --None--" aria-controls="dropdown-element-104"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-104" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="170:0"><label for="cms" data-aura-rendered-by="171:0"><abbr title="required" class="slds-required" data-aura-rendered-by="172:0">*</abbr>Are you
requesting a speaker for Medicaid PHE Unwinding or CMS Regional Office, the Office of Burden Reduction & Health Informatics, the Center for Medicare and Medicaid Innovation, the CMS Office of Communications?</label><lightning-input-field
data-aura-rendered-by="175:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element" lightning-combobox_combobox-host=""><label
lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-109"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>CMS field office</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-109" type="button" aria-expanded="false" aria-haspopup="listbox" name="CMS_field_office__c" data-value="--None--"
aria-label="CMS field office, --None--" aria-controls="dropdown-element-109"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-109" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="176:0"><!--render facet: 177:0--><br data-aura-rendered-by="178:0"><label for="topic" data-aura-rendered-by="179:0"><abbr title="required"
class="slds-required" data-aura-rendered-by="180:0">*</abbr>What is the purpose of the event and what topics would you like CMS to speak on?</label><lightning-input-field data-aura-rendered-by="183:0"
class="slds-form-element"><lightning-textarea class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-63"><abbr
lightning-textarea_textarea="" class="slds-required" title="required">*</abbr>Topics</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-63" name="Topics__c" maxlength="1000" required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="184:0"><label for="attendee" data-aura-rendered-by="185:0"><abbr title="required" class="slds-required" data-aura-rendered-by="186:0">* </abbr>Expected Number Of Attendees
</label><lightning-input-field data-aura-rendered-by="189:0" class="slds-form-element"><lightning-input class="slds-form-element" lightning-input_input-host=""><label lightning-input_input=""
class="slds-form-element__label slds-no-flex slds-assistive-text" for="input-64"><abbr lightning-input_input="" class="slds-required" title="required">*</abbr>Expected Number Of Attendees</label>
<div lightning-input_input="" class="slds-form-element__control slds-grow"><input lightning-input_input="" class="slds-input" type="text" id="input-64" aria-invalid="false" maxlength="20" name="Expected_Number_Of_Attendees__c" required="">
</div>
</lightning-input></lightning-input-field><br data-aura-rendered-by="190:0"><label for="profile" data-aura-rendered-by="191:0"><abbr title="required" class="slds-required" data-aura-rendered-by="192:0">* </abbr>Expected Audience Profile (For
example; Health care providers, Medicare beneficiaries,Administrative staff, Organization members, Congressional staff, etc) </label><lightning-input-field data-aura-rendered-by="195:0" class="slds-form-element"><lightning-textarea
class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-65"><abbr lightning-textarea_textarea="" class="slds-required"
title="required">*</abbr>Expected Audience Profile</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-65" name="Expected_Audience_Profile__c" maxlength="1000"
required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="196:0"><label for="draft" data-aura-rendered-by="197:0"><abbr title="required" class="slds-required" data-aura-rendered-by="198:0">* </abbr>Is A Draft Agenda Currently
Available? (If so, please attach a copy below) </label><lightning-input-field data-aura-rendered-by="201:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist=""
class="slds-form-element" lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-114"><abbr lightning-combobox_combobox="" class="slds-required"
title="required">*</abbr>Is A Draft Agenda Currently Available?</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-114" type="button" aria-expanded="false" aria-haspopup="listbox" name="Is_A_Draft_Agenda_Currently_Available__c" data-value="--None--"
aria-label="Is A Draft Agenda Currently Available?, --None--" aria-controls="dropdown-element-114"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-114" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="202:0">
<h3 class="slds-section-title--divider" data-aura-rendered-by="203:0"> Speaker Details</h3><br data-aura-rendered-by="205:0"><label for="speaker" data-aura-rendered-by="206:0"><abbr title="required" class="slds-required"
data-aura-rendered-by="207:0">* </abbr>If you are requesting a specific CMS speaker(s), please list their name(s) below.</label><lightning-input-field data-aura-rendered-by="210:0" class="slds-form-element"><lightning-textarea
class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-66"><abbr lightning-textarea_textarea="" class="slds-required"
title="required">*</abbr>Specifc Speaker Requested</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-66" name="Specifc_Speaker_Requested__c" maxlength="1000"
required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="211:0"><label for="federal" data-aura-rendered-by="212:0"><abbr title="required" class="slds-required" data-aura-rendered-by="213:0">* </abbr>Are other CMS or Federal
Government employees, Congressional Members or other VIP Officials expected to attend? (If Yes, please specify in Comments) </label><lightning-input-field data-aura-rendered-by="216:0" class="slds-form-element"><lightning-picklist
lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element" lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text"
for="combobox-button-119"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>VIP Officials expected to attend?</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-119" type="button" aria-expanded="false" aria-haspopup="listbox" name="VIP_Officials_expected_to_attend__c" data-value="--None--"
aria-label="VIP Officials expected to attend?, --None--" aria-controls="dropdown-element-119"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-119" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="217:0"><label for="staff" data-aura-rendered-by="218:0"><abbr title="required" class="slds-required" data-aura-rendered-by="219:0">* </abbr>Have you
extended this speaking request to other CMS and/or HHS staff? (If Yes, please provide details below. If No, please enter n/a) </label><lightning-input-field data-aura-rendered-by="222:0" class="slds-form-element"><lightning-textarea
class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-67"><abbr lightning-textarea_textarea="" class="slds-required"
title="required">*</abbr>Other Staff Contacted</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-67" name="Other_Staff_Contacted__c" maxlength="1000"
required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="223:0">
<h3 class="slds-section-title--divider" data-aura-rendered-by="224:0">Additional Details</h3><br data-aura-rendered-by="226:0"><label for="charge" data-aura-rendered-by="227:0"><abbr title="required" class="slds-required"
data-aura-rendered-by="228:0">* </abbr>Is there an admission charge for attendees or speakers? (If Yes, please provide the amount below. If No, please enter n/a)</label><lightning-input-field data-aura-rendered-by="231:0"
class="slds-form-element"><lightning-textarea class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-68"><abbr
lightning-textarea_textarea="" class="slds-required" title="required">*</abbr>Admission Charge?</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-68" name="Admission_Charge__c" maxlength="1000" required=""></textarea>
</div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="232:0"><label for="coverage" data-aura-rendered-by="233:0"><abbr title="required" class="slds-required" data-aura-rendered-by="234:0">* </abbr>Do you anticipate press
coverage?</label><lightning-input-field data-aura-rendered-by="237:0" class="slds-form-element"><lightning-picklist lightning-picklist_picklist-host=""><lightning-combobox lightning-picklist_picklist="" class="slds-form-element"
lightning-combobox_combobox-host=""><label lightning-combobox_combobox="" class="slds-form-element__label slds-assistive-text" for="combobox-button-124"><abbr lightning-combobox_combobox="" class="slds-required" title="required">*</abbr>Do
you anticipate press coverage?</label>
<div lightning-combobox_combobox="" class="slds-form-element__control"><lightning-base-combobox lightning-combobox_combobox="" class="slds-combobox_container" lightning-basecombobox_basecombobox-host="">
<div lightning-basecombobox_basecombobox="" class="slds-combobox slds-dropdown-trigger slds-dropdown-trigger_click">
<div lightning-basecombobox_basecombobox="" class="slds-combobox__form-element slds-input-has-icon slds-input-has-icon_right" role="none"><button lightning-basecombobox_basecombobox=""
class="slds-combobox__input slds-input_faux slds-combobox__input-value" id="combobox-button-124" type="button" aria-expanded="false" aria-haspopup="listbox" name="Do_you_anticipate_press_coverage__c" data-value="--None--"
aria-label="Do you anticipate press coverage?, --None--" aria-controls="dropdown-element-124"><span lightning-basecombobox_basecombobox="" class="slds-truncate">--None--</span></button>
<div lightning-basecombobox_basecombobox="" class="slds-input__icon-group slds-input__icon-group_right"><lightning-icon lightning-basecombobox_basecombobox=""
class="slds-input__icon slds-input__icon_right slds-icon-utility-down slds-icon_container"><lightning-primitive-icon><svg class="slds-icon slds-icon-text-default slds-icon_xx-small" focusable="false" data-key="down"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<path d="M8.3 14h35.4c1 0 1.7 1.3.9 2.2L27.3 37.4c-.6.8-1.9.8-2.5 0L7.3 16.2c-.7-.9-.1-2.2 1-2.2z"></path>
</g>
</svg></lightning-primitive-icon></lightning-icon></div>
</div>
<div lightning-basecombobox_basecombobox="" class="slds-listbox slds-listbox_vertical slds-dropdown slds-dropdown_fluid slds-dropdown_left" id="dropdown-element-124" data-dropdown-element="" role="listbox"></div>
</div>
</lightning-base-combobox></div>
</lightning-combobox></lightning-picklist></lightning-input-field><br data-aura-rendered-by="238:0"><label for="media" data-aura-rendered-by="239:0"><abbr title="required" class="slds-required" data-aura-rendered-by="240:0">* </abbr>Will there
be a request for the Speaker to address media before or after the event? (If Yes, please provide additional details)?</label><lightning-input-field data-aura-rendered-by="243:0" class="slds-form-element"><lightning-textarea
class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-69"><abbr lightning-textarea_textarea="" class="slds-required"
title="required">*</abbr>Request to address Media?</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-69" name="Request_to_address_Media__c" maxlength="255"
required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="244:0"><label for="surrogate" data-aura-rendered-by="245:0"><abbr title="required" class="slds-required" data-aura-rendered-by="246:0">* </abbr>If requested CMS speaker(s) is
not available, is your organization interested in a surrogate? Please place it directly below. If you are requesting a specific CMS speaker(s), please list their name(s) below.</label><lightning-input-field data-aura-rendered-by="249:0"
class="slds-form-element"><lightning-textarea class="slds-form-element" lightning-textarea_textarea-host=""><label lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-70"><abbr
lightning-textarea_textarea="" class="slds-required" title="required">*</abbr>Interested in a surrogate</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-70" name="Interested_in_a_surrogate__c" maxlength="2000"
required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="250:0"><label for="comments" data-aura-rendered-by="251:0"><abbr title="required" class="slds-required" data-aura-rendered-by="252:0">* </abbr>Comments - Please include any
other relevant details not included above</label><lightning-input-field data-aura-rendered-by="255:0" class="slds-form-element"><lightning-textarea class="slds-form-element" lightning-textarea_textarea-host=""><label
lightning-textarea_textarea="" class="slds-form-element__label slds-assistive-text" for="input-71"><abbr lightning-textarea_textarea="" class="slds-required" title="required">*</abbr>Comments</label>
<div lightning-textarea_textarea="" class="slds-form-element__control slds-grow textarea-container"><textarea lightning-textarea_textarea="" class="slds-textarea" id="input-71" name="Comments__c" maxlength="1000" required=""></textarea></div>
</lightning-textarea></lightning-input-field><br data-aura-rendered-by="256:0"><lightning-input data-aura-rendered-by="257:0" class="slds-form-element" lightning-input_input-host="" style=""><span lightning-input_input=""
class="slds-form-element__label" id="form-label-39" data-form-label="">Upload Attachment</span>
<div lightning-input_input="" class="slds-form-element__control">
<div lightning-input_input="" class="slds-file-selector slds-file-selector_files"><lightning-primitive-file-droppable-zone lightning-input_input="" class="slds-file-selector__dropzone"
interop-primitivefiledroppablezone_primitivefiledroppablezone-host="">
<slot interop-primitivefiledroppablezone_primitivefiledroppablezone=""><input lightning-input_input="" class="slds-file-selector__input slds-assistive-text" type="file" id="input-file-39" name="file"
aria-labelledby="form-label-39 file-selector-label-39"><label lightning-input_input="" class="slds-file-selector__body" id="file-selector-label-39" data-file-selector-label="" for="input-file-39" aria-hidden="true"><span
lightning-input_input="" class="slds-file-selector__button slds-button slds-button_neutral"><lightning-primitive-icon lightning-input_input=""><svg class="slds-button__icon slds-button__icon_left" focusable="false" data-key="upload"
aria-hidden="true" viewBox="0 0 52 52">
<g>
<g>
<path d="M48.5 31h-3c-.8 0-1.5.8-1.5 1.5v10c0 .8-.7 1.5-1.5 1.5h-33c-.8 0-1.5-.7-1.5-1.5v-10c0-.7-.7-1.5-1.5-1.5h-3c-.8 0-1.5.8-1.5 1.5V46c0 2.2 1.8 4 4 4h40c2.2 0 4-1.8 4-4V32.5c0-.7-.7-1.5-1.5-1.5z"></path>
<path
d="M27 2.4c-.6-.6-1.5-.6-2.1 0L11.4 15.9c-.6.6-.6 1.5 0 2.1l2.1 2.1c.6.6 1.5.6 2.1 0l5.6-5.6c.6-.6 1.8-.2 1.8.7v21.2c0 .8.6 1.5 1.4 1.5h3c.8 0 1.6-.8 1.6-1.5V15.3c0-.9 1-1.3 1.7-.7l5.6 5.6c.6.6 1.5.6 2.1 0l2.1-2.1c.6-.6.6-1.5 0-2.1L27 2.4z">
</path>
</g>
</g>
</svg></lightning-primitive-icon>Upload Files</span><span lightning-input_input="" class="slds-file-selector__text slds-medium-show">Or drop files</span></label></slot>
</lightning-primitive-file-droppable-zone></div>
</div>
</lightning-input>
<div class="slds-text-body_small slds-text-color_error" data-aura-rendered-by="258:0">No File Selected..</div><br data-aura-rendered-by="260:0"><br data-aura-rendered-by="261:0">
<div class="slds-align_absolute-center" data-aura-rendered-by="262:0"><button type="submit" name="save" class="slds-button slds-button_brand slds-size--3-of-6"
data-aura-rendered-by="265:0"><!--render facet: 266:0-->Submit<!--render facet: 269:0--></button></div>
</form>Text Content
CMS Speaking Engagement Request Form The public is invited to request a CMS representative to speak at an upcoming event. Please complete the form below. All communication from CMS, for both approvals and denials, will be directed to the point of contact listed in the form. Please note: Submitting a Speaking Engagement Request Form does not guarantee that a CMS representative will attend the upcoming event. If you are a member of the press, please do not use this form for interviews or media-related inquiries. For all interviews or media-related inquiries, please visit the CMS Newsroom, by clicking here https://www.cms.gov/newsroom/press-contacts If you would like to request the CMS Administrator to speak at your event, please click here https://www.cms.gov/About-CMS/Public-Affairs/SpeechMeetingRequests/CMS-Speaking-Engagement-Request-Form CONTACT INFORMATION * Event Point of Contact First Name*First Name * Event Point of Contact Last Name*Last Name * Event Point of Contact Title *Event Point of Contact Title * Event Point of Contact Email *Email * Event Point of Contact Work Phone *Event Point of Contact: Work Phone ORGANIZATION INFORMATION * Name of Organization(s) Requesting CMS Speaker *Company * Is this a for-profit or non-profit organization? *Is This A Profit Or Non-Profit ? --None-- * Brief Description of Sponsoring Organization(s)*Activity Objective * Website for Sponsoring Organization *CMS Activity Website and Link EVENT DETAILS * Event Name *CMS Activity Name * Event Start Date *Event Start(new) Select a date for Event Start(new) * Event End Date *Event End(New) Select a date for Event End(New) * Event Start Time*Event Start Time --None-- * Event End Time*Event End Time --None-- * Event Time Zone*Event Time Zone --None-- *If event spans multiple days, what specific date and time are you requesting a CMS speaker? *For what date(s) and time(s) *Is the event open to the public, open to members, or by invitation only? *Open To The Public Or Invitation Only? --None-- *Requested Presentation Medium *Requested Presentation Medium --None-- *Event Location (e.g., name of hotel or conference center; if virtual, please enter intended web platform) *Location * Event Address (if virtual, please enter n/a) *Address *Event Zip Code (If virtual, please enter your Organization's zip code) *Zip Code *Requested Presentation Format *Requested Presentation Format --None-- *Are you requesting a speaker for Medicaid PHE Unwinding or CMS Regional Office, the Office of Burden Reduction & Health Informatics, the Center for Medicare and Medicaid Innovation, the CMS Office of Communications?*CMS field office --None-- *What is the purpose of the event and what topics would you like CMS to speak on?*Topics * Expected Number Of Attendees *Expected Number Of Attendees * Expected Audience Profile (For example; Health care providers, Medicare beneficiaries,Administrative staff, Organization members, Congressional staff, etc) *Expected Audience Profile * Is A Draft Agenda Currently Available? (If so, please attach a copy below) *Is A Draft Agenda Currently Available? --None-- SPEAKER DETAILS * If you are requesting a specific CMS speaker(s), please list their name(s) below.*Specifc Speaker Requested * Are other CMS or Federal Government employees, Congressional Members or other VIP Officials expected to attend? (If Yes, please specify in Comments) *VIP Officials expected to attend? --None-- * Have you extended this speaking request to other CMS and/or HHS staff? (If Yes, please provide details below. If No, please enter n/a) *Other Staff Contacted ADDITIONAL DETAILS * Is there an admission charge for attendees or speakers? (If Yes, please provide the amount below. If No, please enter n/a)*Admission Charge? * Do you anticipate press coverage?*Do you anticipate press coverage? --None-- * Will there be a request for the Speaker to address media before or after the event? (If Yes, please provide additional details)?*Request to address Media? * If requested CMS speaker(s) is not available, is your organization interested in a surrogate? Please place it directly below. If you are requesting a specific CMS speaker(s), please list their name(s) below.*Interested in a surrogate * Comments - Please include any other relevant details not included above*Comments Upload Attachment Upload FilesOr drop files No File Selected.. Submit