IDPH Community Event Request Form

Health Screenings

For Health Screening Events, please submit a request to the Wellness on Wheels event request form instead of using this form. Your health event will then be routed to the appropriate party. CLICK HERE: https://app.smartsheet.com/b/form/64a43e0cf1a24c908d35a829f40056eb

COVID-19 Vaccine Clinic

For COVID-19 Mobile Vaccination Clinics, please use the Vaccination Clinics event request form instead of using this form. Your vaccine clinic request will then be routed to the appropriate party. CLICK HERE: https://dph.illinois.gov/covid19/vaccinationclinics1.html

Other Event Type*

Please explain the type of event you are hosting.

Presentation Type*

Select up to two:

Select

Meeting Presentation Type

Select

Speaking Engagement Type*

Select

NOTE: Your Event Must Be Free to the Public

The Illinois Department of Public Health does not participate in health fair events that charge admission fees. The event must be free to the public.

By checking this box, you confirm that your event is FREE to the public*

Virtual/In-Person*

Virtual/Online Only

Physical/In-Person Only

Both Virtual and In-Person Options

Event URL*

Please provide the URL (link) to the online event. If there is no link yet, please indicate so.

Event Date*

What is the date of your event? For multiple-day events, use the first date of the event.

PLEASE NOTE:

Events occurring with less than 4 weeks notice may not be accommodated due to limited availability.

Event Start Time*

What time will the event begin?

Select

Event End Time*

What time will the event end?

Select

RSVP by*

By what date would you need a response from IDPH?

Hosting Organization*

Who is hosting this event?

Primary Contact Name*

Please provide the First and Last name of the Primary Contact for this event.

Primary Contact Phone*

Please provide the best phone number to reach the Primary Contact regarding this event.

Phone

Primary Contact Alternative Phone

Please provide an alternative phone number in case we cannot reach the primary phone number.

Phone

Primary Contact Email*

Please provide the best email address to contact the Primary Contact regarding this event.

Event Street Address*

Provide the building number and street name for the location of your event.

Event City*

Select

Event State*

IL

Event Zip*

Expected Attendance*

How many people do you expect to attend your event?

Tables/Chairs*

Will you be able to provide all the necessary tables/chairs or other equipment for the event?

Select

Additional information for Tables and Chairs*

If you are unable to provide the necessary tables/chairs/equipment for this event, please explain below. If you are requesting any equipment from IDPH, please explain. Not all requests may be accommodated. Based on availability.

Target Audience - Race/Ethnicity*

What are the race/ethnicities of the people you expect to attend your event? You may select multiple race/ethnicities, or ALL.

Other Race/Ethnicity*

Media Expected*

Select

Media Description*

Please name/describe the media outlets you expect to be present.

Written Materials Language*

Select all that apply: If you need written materials, which languages will you need? (Not all requests may be fulfilled - based on availability.)

Select

Other Translated Materials*

If the language you need materials for is not listed, please list below.

Additional Information Regarding Speaking Engagement

Please provide a detailed description of your request for a speaking engagement from the IDPH Director/Assistant Director.