Sirs Moe

SI SIRS MEDIA OUTREACH AND EDUCATION FORM
Type of Interaction *:	Media Outreach & Education
Session Conducted By*: Date of Interaction (MM/DD/YYYY)*: End Date (if applicable): Date of Initial Creation: Auto-Populated Zip code*: State*: County:					Title of Interaction: Time Spent in Minutes*: Reference Number: Auto-Populated Organization: Auto-Populated
Notes:
ACL/SMP Consumer Alert*:			Yes		No
Type of Media:			Billboard Email Magazine Newsletter		Newspaper Radio Social Media	Television Website Other
Geographic Coverage:			County or Counties Multi-State		National Regional	Statewide Zip Code
Specific Coverage Location:
Intended Audience:			Beneficiaries Family Members/ Caregivers General Audience		Health Care Providers Law Enforcement	Partner Organizations Other
Topic(s) Discussed:
Conditional Payments Consumer Protection Durable Medical Equipment (DME) Employer Health Plan General Fraud Errors, and Abuse Genetic/DNA Testing Home Health Care Hospice Medicaid Medical Identity Theft Medicare Advantage Medicare Part A and B				Medicare Part D Medicare Summary Notice Medigap or Supplemental Insurance Medicare Card Substance Misuse/Fraud /Abuse SMP Program Information SMP Volunteer Recruitment Social Security TRICARE Veteran’s Health Benefit Other
Other Topics Discussed Details:
Estimated Number of People Reached*:
Basis of Estimate of Number of People Reached:
In-Kind Match (xxxx.xx):

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.