Stars Moe

STARS MEDIA OUTREACH & EDUCATION FORM
* Items marked with asterisk (*) indicate required fields
Start Date of Activity *: __________________ End Date of Activity: __________________
MIPPA Event *:	Yes			No
Send to SMP:	Yes		No			SIRS eFile ID: (*required if sending record to SMP)			________________________
Event Details *
Session Conducted By *: ____________________________________________________							Partner Organization Affiliation* : ____________________________________________________
Total Time Spent on Event *: _____________Hours _____________Minutes							Title of Interaction *: ____________________________________________________
Type of Media * (select only one):							Estimated Number of People Reached: _____________________
Billboard Email Magazine Newsletter Newspaper		Radio Social Media Television Website Other					Geographic Coverage (select only one):
							County or Counties Multi-State National			Regional Statewide Zip Code
Event Location *
State of Event * : __________________ Zip Code of Event * : __________________ County of Event * : _____________________________________
Media Contact Information
Media Contact First Name: ____________________________________________________ Media Contact Last Name: ____________________________________________________							Media Contact Phone: ____________________________________________________ Media Contact Email: ____________________________________________________
Intended Audience * (multiple selections allowed):
Beneficiaries Employer-Related Groups Family Members/Caregivers					Medicare Pre-Enrollees Partner Organizations			Other
Target Beneficiary Group * (multiple selections allowed):
American Indian or Alaskan Native Asian Black or African American People with Disabilities Native Hawaiian or other Pacific Islander					Hispanic/Latino Limited English Proficiency Low Income LGBTQI+			Rural N/A Other
Topics Discussed * (multiple selections allowed):
Duals Demonstration Extra Help/LIS General SHIP Program Information Long-Term Care Insurance Medicaid Medicare Advantage					Medicare Fraud and Abuse Medicare Part D Medicare Savings Program Medigap or Supplemental Insurance Original Medicare (Parts A and B) Other Prescription Drug Coverage			Partnership Recruitment Preventive Services Substance Misuse/Fraud/Abuse Volunteer Recruitment Other
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Special Use Fields

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Notes

Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 0985-0040). Public reporting burden for this collection of information is estimated to average 4 minutes per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain benefits.