Contact Information
* Indicates required field.

1. * First Name
2. * Last Name
3. * Department or Organization
4. * Phone (e.g. xxx-xxx-xxxx)
5. * Email
6. * Email Confirmation

Consultation Information

1. *Type of Educational Resources

   Inclusive Teaching Strategies Campus Climate Bias & Microaggressions Facilitating difficult conversations Other
2. If other, please indicate
   type of training.
3. * Audience

   Faculty Staff Students
4. *What prompted this request?
5. *Educational Goals & Outcomes
   (area which needs special focus)
6. *Number of Attendees
7. * Are attendees required to be there?

   Yes No
8. *Educational Presentation(s) & Consultations
   (building and room number)
9. *Are there any accommodations needed?
   (For example, assistance for those who are blind, deaf, or need interpreters)

Preferred Dates and Times

1. Please indicate the dates and times you would like the educational presentation or consultation. We will make every effort to accommodate your first choice. A minimum of three weeks advance notice is required.
2. *First Choice Date (mm/dd/yyyy)
3. *First Choice Time Range
   to
4. *Second Choice Date
   (mm/dd/yyyy)
5. *Second Choice Time Range
   to
6. *Third Choice Date (mm/dd/yyyy)
7. *Third Choice Time Range
   to

Room Capabilities for Presentation & Consultations

1. * PowerPoint projection ready?

   Yes No
2. If there is no PowerPoint projection ready, what equipment is available?
3. * Audio Available?

   Yes No