Form 2 Media Group Outreach Events Form

MEDIA OUTREACH & EDUCATION FORM

OMB No. 0985-0040

* Items marked with asterisk (*) indicate required fields
MIPPA Event *:
 Yes
 No
SIRS eFile ID:
 Yes
 No
Send to SMP:
(*required if sending record to SMP)
Event Details *
Session Conducted By *:
Partner Organization Affiliation* :

Total Time Spent on Event *:

Title of Interaction *:

Hours

Minutes

Type of Media * (select only one):

Estimated Number of People Reached:

 Billboard



Radio

 Email



Social Media

 Magazine



Television

 Newsletter



Website

 Newspaper



Other

Start Date of Activity *:

Geographic Coverage (select only one):


County or Counties



Regional



Multi-State



Statewide



National



Zip Code

End Date of Activity:

Event Location *
State of Event * :

Zip Code of Event * :

County of Event * :
Media Contact Information
Media Contact First Name:

Media Contact Phone:

Media Contact Last Name:

Media Contact Email:

Intended Audience * (multiple selections allowed):
 Beneficiaries
 Limited-English Proficiency
 Employer-Related Groups
 Medicare Pre-Enrollees
 Family Members/Caregivers
 Partner Organizations
Target Beneficiary Group * (multiple selections allowed):
 American Indian or Alaskan Native
 Hispanic/Latino
 Asian
 Languages Other Than English
 Black or African American
 Low Income
 Disabled
 Native Hawaiian or other Pacific
Islander
Topics Discussed * (multiple selections allowed):
 Duals Demonstration
 Medicare Fraud and Abuse
 Extra Help/LIS
 Medicare Part D
 General SHIP Program Information
 Medicare Savings Program
 Long-Term Care Insurance
 Medigap or Supplemental Insurance
 Medicaid
 Original Medicare (Parts A and B)
 Medicare Advantage
(Continued on p.2)

 People with Disabilities
 Rural Beneficiaries
 Other





Rural
N/A
Not Collected







Other Prescription Drug Coverage
Partnership Recruitment
Preventive Services
Volunteer Recruitment
Other

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Notes