1 Start 2 Complete What type of Service are you requesting? Service Request Please fill out separate request forms if you have multiple service requests. Implicit Bias Training Responding Effectively to Mistreatment (Bystander to Upstander) Training Culturally Responsive Care Training Sexual Orientation and Gender Identity (SOGI) Phase I: LGBTQ 101 for Health Care Professionals SOGI Phase II: Caring for Transgender Patients "“What to Say”: Responding to Patient-Initiated Discriminatory/Biased Disruptive Behavior" Fair Search and Hire Practices Training Generational Issues in the Workplace Other Training/Workshop (specify below) Panel (briefly describe below) Speaking Request (briefly describe below) Brief Description/Specification Title/Name of Event Department/Unit Date and TimePlease indicate the expected time frame you hope to have this service request fulfilled. Expected date/time Flexible (i.e. there is no required time frame) Firm (i.e. the date, month, or time frame has already been selected) Proposed Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Proposed Time Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Duration of Event Location of Event Building/Room Number as well as specific location Contact Person Name E-mail Phone number AudiencePlease indicate intended audience members. Select all that apply. Intended audience Faculty Staff Residents/Fellows Undergraduate Students Medical/PA Students Nurses Social Workers PhD Students PostDocs PT Students Other Graduate/Professional Students Community Members Other Estimate attendance How many people do you estimate will be in attendance? Tell us more about your specific request Share the purpose of the event, what is the projected outcome of holding this event, etc (i.e., faculty/staff development/recognition, student recruitment, alumni/community/donor relations)? Also history of event and any suggested speaking points, if relevant. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.