Form 3 Resource Report

TEAM MEMBER FORM

OMB No. 0985-0040

* Items marked with asterisk (*) indicate required fields

Team Member Name
First Name *:

Middle Initial:

Last Name *:

Nickname:

Team Member Contact Information
Primary Phone Number *:

Address:

Primary Phone Number Extension:

City:

Secondary Phone Number :

Zip Code *:

Secondary Phone Number Extension:

State/Territory *:

Email Address:

County *:

Team Member Details
Partner Organization Affiliation *
(Indicate primary org. that team member is affiliated with):

Start Date * :

End Date (if applicable):

Status * (Select only one):
 Active

Paid Status * (Select only one):

 Inactive

 Retired

 In-Kind-Paid

 SHIP-Paid

 Volunteer

Team Member Demographic Information
Race * (Multiple selections allowed):
 American

 Native

Indian or Alaskan Native

Asian
Black

Hawaiian or Other Pacific Islander

 White
 Not Collected

or African American

Hispanic

or Latino

Date of Birth *:

Gender * (Select only one):



Female

 Male

 Other



Not Collected

Team Member Demographic Information (continued)
Primary Language *

Secondary Language:

(Select only one):

(Select only one):



English



English



Chinese



Chinese



Korean



Korean



Russian



Russian



Spanish



Spanish



Vietnamese



Vietnamese



Other



Other

Team Member STARS Details
Role * (Select only one):


SHIP Assistant Director



State Staff



Sub-State Manager



Site Manager



Team Member



Sub-State Staff



STARS Submitter



Site Staff

Send Login Credentials:

 Yes

 No

Revoke Login:

 Yes

 No

 SHIP

 SMP

Program * (Multiple selections allowed):

(Enter SIRS eFile ID, if applicable):

 MIPPA

Team Member Unique ID Details
Create 1-800 Medicare Unique ID Number *:

 Yes

 No

Send 1-800 Medicare Unique ID Number:

 Yes

 No

Status of 1-800-Medicare Unique ID Number * :



 Inactive

Notes

Active