Diversity Education Request Form

Please answer each question below as completely as possible to request one of our eight signature diversity education workshops (Inclusive Excellence 101-801 listed below) or to arrange a customized workshop for a group. Be sure to submit your request at least 2 months in advance of the desired training date. Upon receipt of your submission, a representative from our office will contact you within 5 business days to schedule a consultation to discuss logistics and any specific needs. A consultation must take place before a workshop can be confirmed. If you have any questions, contact the Director of Operations, Jermaine Soto, at jermaine.a.soto@vanderbilt.edu. Thank you for your interest in diversity education through the Office for Equity, Diversity, and Inclusion.

Group Requesting Presentation
Contact's Name Contact's Name First Last
Phone Phone - ### - ### ####
Email
A. EXISTING EDUCATION SERIES
Identify the existing educational workshop(s) in which you are interested from the list below, and complete Section C. Unless noted, workshops are one hour in length. Inclusive Excellence 101 is a prerequisite for Inclusive Excellence 201. All other classes can be taken in any order.

Identify the existing educational workshop(s) in which you are interested from the list below, and complete Section C. Unless noted, workshops are one hour in length. Inclusive Excellence 101 is a prerequisite for Inclusive Excellence 201. All other classes can be taken in any order. Inclusive Excellence 101: Unconscious Bias – A New Look at an Old Dynamic! (Two hours) Inclusive Excellence 201: Everyday Bias – Cook Ross (Two hours) Inclusive Excellence 301: Unconscious Bias – Next Steps Inclusive Excellence 401: Effective Communication and Collaboration across Diverse Groups Inclusive Excellence 501: Allyship and Relationship-Building Inclusive Excellence 601: Inter- and Intra-Racial and Ethnic Dynamics (Part 1) Inclusive Excellence 701: Inter- and Intra-Racial and Ethnic Dynamics (Part 2) Inclusive Excellence 801: Families, Friends, and Relationships
B. CUSTOM EDUCATION TRAINING
Purpose/Goal of Diversity Education (provide as much detail as possible)
C. LOGISTICS
Anticipated Audience
Demographics
e.g., Will middle managers, front-line personnel, or administrators attend? In addition, what kind of diversity can be expected in terms of factors such as gender, age, and race?
Anticipated Number of Attendees
Key attendees (e.g., department/area, leadership program, etc.)
Will attendees RSVP? If so, please indicate RSVP cutoff date Will attendees RSVP? If so, please indicate RSVP cutoff date / MM / DD YYYY
Are there any special needs for attendees (e.g., visual/audio aid or English proficiency support)?
Meeting Details
Requested Length of Training
Requested Start Time Requested Start Time : HH MM AM/PM
Will the requested diversity training be part of a larger meeting/workshop?

Will the requested diversity training be part of a larger meeting/workshop? Yes No
Timeframe for the full meeting/workshop
What is taking place before the training?
What is taking place after the training?
How much time is available for set-up prior to the training?
Technology Contact Person’s Name Technology Contact Person’s Name First Last
Technology Contact Person’s Phone Technology Contact Person’s Phone - ### - ### ####
Technology Contact Person’s Email
Location Details
Will the presentation take place on campus?

Will the presentation take place on campus? Yes No
Has a training location been secured?

Has a training location been secured? Yes No
Building Name
Physical Address Physical Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Floor
Room Number/Name
Is parking available?

Is parking available? Yes No
If yes, please provide location
Does the room provide wheelchair access?

Does the room provide wheelchair access? Yes No
Equipment & Space Details
Please check each item that is available in the meeting space

Please check each item that is available in the meeting space Projector Projector Screen Lectern On-site AV Tech On-call AV Tech Complimentary Wi-Fi CODE House sound On-site temperature control Table for handouts Open space for interactive activities Access to space 24-36 hours prior to presentation (required)
Seating Arrangements

Seating Arrangements 60” rounds 72” rounds 6 ft. rectangle 8 ft. rectangle
Feedback Surveys
In an effort to continually improve our diversity education process, attendees will be asked to complete a short feedback survey at the end of the workshop. For certain workshops, attendees may also be asked to complete short pre- and post-workshop surveys. Can your attendees complete feedback surveys?

In an effort to continually improve our diversity education process, attendees will be asked to complete a short feedback survey at the end of the workshop. For certain workshops, attendees may also be asked to complete short pre- and post-workshop surveys. Can your attendees complete feedback surveys? Yes No

Diversity Education Request Form

Diversity Education Request Form

A. EXISTING EDUCATION SERIES

B. CUSTOM EDUCATION TRAINING

C. LOGISTICS

Anticipated Audience

Meeting Details

Location Details

Equipment & Space Details

Feedback Surveys