ACF Speaking Request Form_5.17.22

Administration for Families and Children

External Speaker Request Form

Thank you for contacting the Administration for Children and Families (ACF). We appreciate your interest in inviting ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – to participate in speaking engagements, presentations, interviews, and other external events. In addition to this form, we require a formal letter of invitation on your organization’s letterhead. Please also provide a short bio for each distinguished guest in attendance. You can also submit any supplemental material that you feel would also be useful in rendering a decision, limited to four pages. In order to receive full consideration, we request that you submit this form along with any supporting materials at least 12 weeks prior to the event date.

For more specific instructions and questions please direct them to [email protected] or contact the office at (202) 740-6961.Tms & Conditions

A letter confirming receipt of your request will be emailed to you. We will confirm or decline requests for ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – attendance at a conference or event approximately one month to six weeks prior to the date of the event.

You should not include the name or title of any ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – in any materials until we confirm attendance or participation. You also should not list ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – as "invited" until we confirm attendance or participation.

ACF LEADERSHIP OR SUBJECT MATTER EXPERTS – THE ASSISTANT SECRETARY, PROGRAM LEADERSHIP, OR PROGRAM STAFF – PARTICIPATION IN SPEAKING ENGAGEMENTS, PRESENTATIONS, INTERVIEWS, AND OTHER EXTERNAL EVENTS: INFORMATION FOR OUTSIDE ORGANIZATIONS CONCERNING PROHIBITED GIFTS

Organizations that invite ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – to speak or otherwise participate in their events or activities often ask whether gifts or other tokens of appreciation are permissible. An Executive Order precludes, subject to certain exceptions, ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – from accepting gifts valued at any amount from registered lobbyists and lobbying organizations. Gifts received from media organizations or 501(c)(3) nonprofit organizations are not subject to the lobbyist gift ban provided that the employee of the organization offering the gift is not a registered lobbyist. Additionally, federal ethics regulations prohibit, subject to certain exceptions, any federal government employee, including ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – from personally accepting honoraria, gifts, favors, opportunities, benefits, discounts, or other items of value worth more than $20 that are offered as a result of official position or tendered by those who may have matters before the Department of Health and Human Services (HHS). The following items, however, may be offered and accepted without regard to the $20 limit or the lobbyist gift ban, except where noted in italics.

• Modest items of food and refreshments, such as soft drinks, coffee, and donuts, offered other than as part of a meal.

• Food, refreshments, and entertainment offered in a group setting with other attendees at an event or conference at which ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – will deliver official remarks as a speaker or panel participant, if provided by the sponsoring organization on the day of the ACF leadership or subject matter expert presentation.

• Food, refreshments, and entertainment at a widely attended gathering for which there is an agency interest in ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – attendance, if the invitation has been tendered directly by the sponsoring organization that is holding the event. An invitation from a third party who has purchased tickets to the event cannot be accepted unless more than 100 persons will attend, and the market value of free attendance is $350 or less. Complimentary widely attended gathering invitations from registered lobbyists or lobbying organizations, other than nonprofit or media organizations may not be accepted.

• Plaques, certificates, and trophies that are intended solely for presentation and that have little intrinsic value are acceptable tokens of appreciation. (Note that art objects, glass works, sculptured trophies and similar items that have residual value or utility, even where diminished by an engraving, logo, or other marking, may not be accepted personally as a token of appreciation. Under certain circumstances, such valuable items may be presented to ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff – but these gifts must be treated as gifts to HHS for retention or display in accordance with applicable regulations.)

• Native artwork, crafts, or other items representative of traditional native culture offered by Indian tribes or Alaska native villages that do not exceed $200 in value. (Note that if the tribe or village has specific matters presently pending for decision by HHS, then acceptance is permitted only upon a written determination of agency interest.)

• Food, refreshments, and entertainment, as well as tangible items of appreciation, valued at $350 or less offered by foreign governments, foreign political parties, and international or multinational organizations of which the United States is a member. Tangible items exceeding $350 may be accepted on behalf of HHS for retention or display in accordance with applicable regulations.

• Food, refreshments, and entertainment at a meeting or event in a foreign country attended by foreign nationals and offered by persons or organizations other than a foreign government, if the value does not exceed the Department of State’s maximum per diem rate for that area. Complimentary hospitality tendered in a foreign country by registered lobbyists or lobbying organizations, other than nonprofit or media organizations may not be accepted.

Other rules apply to honorary degrees and awards for meritorious public service or achievement that include gifts of monetary value or that are signified by presentation items other than plaques, certificates, or trophies. These situations must be reviewed and approved in advance by HHS. Your assistance in ensuring compliance with these requirements will avoid an awkward or embarrassing situation in which items tendered impromptu must be declined or returned. Your cooperation in advising ACF of any proposed gifts is appreciated.

Form begins here – should be created with the webpage software with the following specifications:

Speaker Requested: *(create dropdown with list Assistant Secretary for ACF; Principal Deputy Assistant Secretary for ACF; other – with ability to type in another name)

Would you be willing to accept a surrogate speaker if the one you have requested is unable to participate? *(create drop down with Yes or No – with ability to comment)

Inviting Organization/Individual: *(ability to enter this information)

Is the inviting organization a 501(c)(3)? *(Create drop down with Yes or No)

Organization Description: *(create ability to enter a brief summary of the organization with word or character limit)

Organization Website: * (provide ability to enter this information)

Event Name: *(provide ability to enter this information)

Event Type: *(create dropdown including: meeting; briefing; conference/summit; reception; awards ceremony; retirement; webinar; roundtable; other – with ability to type in this information)

Event Topic: *(provide ability to enter this information)

Event Description: *(provide ability to enter this information)

Event Start: *(create drop down calendar)

Event End: *(create drop down calendar)

Open Ended Event Date: (provide box to check)

Speaking/Presentation Date: * (create drop down calendar)

Deadline to receive speaker confirmation: * (create drop down calendar)

Speaking Start Time: * (create dropdown times HH:MM)

Is speaking start time flexible? * (create drop down Yes or No)

Speaking End Time: *(create dropdown times HH:MM)

Event Time Zone: *(provide ability to enter this information or in the alternative create dropdown EDT, EST, CDT, etc…)

Speaking Duration: * (create dropdown for time in 15-minute intervals)

Q&A Duration: * (create dropdown for time with “none” and then 15-minute intervals)

Type of Participation: * (create dropdown with keynote; remarks; fireside chat; panel discussion; breakout session; other – with ability to type in this information)

Proposed Speaking Topic(s): *(provide ability to type in this information)

Speaking Topic Details:* (Provide ability to enter more details regarding the requested speaking topic(s) with word/character limit).

Event Venue Name:* (provide ability to enter this information – add line “If the event is virtual, enter “n/a” for event location fields.”)

Event Street Address:*(provide ability to enter this information)

Event City:* (provide ability to enter this information)

Event State:* (create state dropdown including Virgin Islands, Puerto Rico, Guan and DC)

Event Country:* (create country dropdown)

Event Zip Code:* (provide ability to enter this information)

Audience Size:* (provide ability to enter this information)

Audience Composition & Proportions:* (provide ability to enter details about makeup of expected audience members.)

Formally Recorded or Published?* (create dropdown with Yes or No)

What types of media are invited to the event?* (Create dropdown list with: broadcast; print; web; local; regional; national; live webcast; media not invited – Add statement: Select all that apply – to select multiple options, hold down Ctrl while making your selections)

Please provide information on any other HHS officials speaking at this event?* (provide ability to enter this information.)

Please provide the names and titles of the other speakers/panelists: (provide ability to enter this information.)

Please provide names, titles, and organizations of distinguished guests, including elected officials, expected at this event:*(provide ability to enter this information.)

Please provide the names of any registered lobbyists who will be in attendance:* (provide ability to enter this information.)

Is there a fundraising component to this event?* (create dropdown Yes or No)

Is an award, certificate, gift, or other item being presented to the speaker?*(create dropdown Yes or No – for yes, create pop up box with please describe)

Do any promotional materials for the event include the speaker's name?* (create dropdown Yes or No – for yes, create pop up box with please describe)

Is this event open to the general public or available through an individual invitation only?* (create dropdown box with Open to Public; By Invitation Only)

What is the cost of attendance for a member of the general public through ticket or registration fee?* (provide ability to enter this information)

If there is no publicly available ticket price or registration fee, what is the cost per person for the event organizer to host the event?* (provide ability to enter this information)

Are there any separately ticketed portions of this event or meals or activities that are not included in the registration fee?* (provide ability to enter this information)

Is a spouse or other guest invited? If so, will the majority of participants be accompanied by a guest?* (provide ability to enter this information)

Event Contact Name:* (provide ability to enter this information)

Event Contact Title: * (provide ability to enter this information)

Event Contact Email:* (provide ability to enter this information)

Event Contact Phone:* (provide ability to enter this information)

Public Affairs/Media Contact Name:* (provide ability to enter this information)

Public Affairs/Media Contact Title:* (provide ability to enter this information)

Public Affairs/Media Contact Email:* (provide ability to enter this information)

Public Affairs/Media Contact Cell:* (provide ability to enter this information)

Public Affairs/Media Contact Office:* (provide ability to enter this information)

Create ability for attachments (e.g., formal request letter, agenda, promotional materials, etc.)

*denotes required information

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to help the Administration for Children and Families (ACF) respond to requests for ACF leadership or subject matter experts – such as the assistant secretary, program leadership, or program staff to attend speaking engagements, presentations, interviews, and other external events. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering, and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531 and the expiration date is 07/31/2022. If you have any comments on this collection of information, please contact [email protected] or contact the office at (202) 740-6961.