Workshop Request Form

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Name

First Last Email Phone Department or University Affiliation

First Choice

Date *

Start Time * :

End Time * :

Second Choice

Date *

Start Time * :

End Time * :

Topic Request

Cultural Humility Importance of Diversity at IU School of Medicine Microaggressions and Intercultural Communication Barriers Multicultural Competence 101 Safe Space Training Unconscious Bias

What is the goal for the workshop?

Workshop Location

Enter “TBD” if pending. Once location is confirmed, send exact location to Diversity Affairs.

Who is the primary audience? Select all that apply. Volunteer Faculty Staff Residents Fellows Medical Students All Learners General Public

Estimated Attendance

Workshop Request Form

Name

First Choice

Second Choice

Topic Request

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