• Services Request *
  • Directions

    Please fill out all required information (a red asterisk will indicate). Scroll down to see each service the EWD branch has to offer. The services will be titled with their own instructions underneath each title. Please read the instructions before sending the form.

  • Today's Date*
  • Email Address*
  • Contact Name *
  • Phone Number*
  • Department of Public Health Branch*
  • If Other, Please Specifiy
  • Title of Course*
  • Brief Description of Event/Course *
  • Recurring Program (module request n/a)
  • Date/Dates of the Event*
  • Start Time of the Event (EST)*
  • End Time of Event (EST)*
  • Specific Request Needed
  • Directions

    **Should you need equipment other than what is already provided in the rooms, please be prepared to bring the necessary items with you. **If you need technical assistance for you meeting, be sure to make arrangements 5 business days in advance with the chfsnetworkhelpdesk@ky.gov. The EWD Branch is not responsible for providing technical assistance. ** In the event of a DPH emergency and/or the activation of the DOC, these room reservations are subject to relocation or cancelation.

  • Estimated Attendance
  • Technical Assistance Needed
  • If yes, specify the time you will need the technical assistant to arrive
  • Equipment Needed
  • Directions

    The EWD Branch is only responsible for scheduling the room for you. If you require IT assistance the day of your meeting. It is your responsibility to make arrangements with the DPH Helpdesk at chfsnetworkhelpdesk@ky.gov at least 5 business days in advance of your presentation.

  • Target Audience
  • Program Content Contact
  • I want to open this program to all DPH Videoconferencing Sites?
  • I only want the following sites to have access:
  • Will the program be on TRAIN?
  • Will you need this program recorded and/or webcasted?
  • Will broadcast media be used in this videoconference (ie. PowerPoint Presentation or Internet Access)?
  • Description Text

    Must have the approved short Curriculum Vitae (CV) form completed and returned (Utilizing the link below.) The course cannot be approved for continuing education credit until a CV is received for each content presenter.

  • CV Link (copy and paste into browser)

    https://prd.chfs.ky.gov/cvform/

  • Agenda: (Please copy and paste in box) * Session time (Must include time for breaks and meals in the agenda.) * Title of each session * Presenter(s) name and their credentials for each session **If Agenda will not fit please email to the EWD Mailbox
  • Planning Committee: (Please copy and paste to this form) Must include at least one Registered Nurse if request nursing contact hours. Must include at least one Dietitian if request Dietetic CPE.
  • Online Module or Webcast – (Identify content person that participants can email with their questions)
  • Registration Deadline
  • Select discipline to receive CE's
  • Format (check all that apply)
  • Description of the Training
  • Learning Objective
  • Subject Matter/Content Expert
  • Module Description
  • Estimated Completion Date
  • Directions

    Attention: Videographer will arrive at the location 30 minutes to 1 hour prior to the time of the event to setup. Persons being videotaped need to sign a release form. If minors are to appear in the video, their parents/legal guardian must sign the Minor Release Form. *Requester must have a script developed prior to taping. The videographer can assist in the development of video scripts. Please contact chfs.ewd@ky.gov for assistance.

  • Contact Person at the event (if different than Contact Person)
  • Location of Taping
  • Title of Taping
  • Type of Taping
  • If other, please specify
  • Final Product will be:
  • Time
  •