CDD REACH Request Form

Webinar

Event Information / Will private health information be discussed?
Title of Event: / Yes / No
Requested by: / Are some participants connecting by webinar and others by video conference?
Phone Number: / Yes / No
E-mail: / Should event be recorded?
CDD Program: / Yes / No
Date Request Submitted: / Purpose of Event
# attending at CDD: / Technical Assistance (TA)
Preferred CDD Room: / Training CMEs CEUs
Estimated # attending at other places: / Administrative Meeting
(include multiple dates if this is a recurring event,
and a date for practice session if desired) / Clinical – Patient
Date / Start and End Times / Clinical Consultation / Case Review
Other:
Presentation Media (check all that apply)
PowerPoint
Internet (does internet site use sound? Yes No)
DVD/VHS
Event Type / Other Documents (pdf or shown from desktop)
Training Webinar (presenting information to 5 + participants) / FlashVideo Clips (.flv or .f4v files)
Collaborative Meeting (small group, everyone talks) / Extra Notes or Questions for REACH Staff
Other:
Presenters or Essential Participants not at CDD
(city or organization)
Location / # People / Name / Phone # / E-mail
1
2
3
4
Webinar Audio Considerations
Audio may be presented over the internet, by phone conference call, or both.
Where will theparticipants will be?(check all that apply, but don’t count yourself or your webinar assistant)
At computers with internetaccess (individually or as a group)
In groups at videoconferencing sites
Part of a live audience with the presenter
Viewing a recording of the presentation at a later time
Other (please specify):
How will you handle Q and A? (check all that apply)
Participants will discuss/ask questions vocally Requires a backup phone or conference call
Participants will ask questions via a chat box that is part of the webinar software
REACH recommends encouraging participants to use the webinar audio over the internet with a conference call as a back-up method to listen to the event in case of technical difficulties
Participants will be listening only, not asking questions
REACH recommends encouraging participants to use the webinar audio over the internet with a conference call as a back-up method to listen to the event in case of technical difficulties
Other (please specify):
Conference Call Information (A conference call is recommended for all webinars)
REACH RollCall Account $.05/minute/line Index Code for billing:
Other phone conferencing
Dial in #: Moderator Pin: Participant Pin
Phone call or 3-way call (Only use if connecting to 1 or 2 other locations. Please bring your long distance code and
the phone #s of your participants)

Please return request form to CDD REACH via e-mail, in-person or fax

Last modified: 07-01-2011at 505-272-3844, fax 505-272-5883. Page 1