CMS-10028-C State Health Insurance Assistance Program (SHIP) Resourc

OMB No. 0938 - 0850

State Health Insurance Assistance Program (SHIP) Resource Report Form
Name of Grantee Agency Reporting

State

6-month Report Period:
______ / ______ to ______ / ______

Person Completing Report

Title

Telephone No.

month

SECTION 1 - NUMBER OF
ACTIVE COUNSELORS AND
HOURS

State
Office

All Other
Local and TOTAL
Field Sites

/

year

month

year

SECTION 2 - NUMBER OF LOCAL COORDINATORS/SPONSORS
AND HOURS

a. # Volunteer Counselors

a. # Volunteer (unpaid) Coordinators

b. # SHIP-Paid Counselors

b. # SHIP-Paid Coordinators

c. # In-kind Paid Counselors

c. # In-kind Paid Coordinators

TOTAL

TOTAL # Coordinators (a+b+c)

TOTAL # Counselors (a+b+c)
d. Volunteer Counselor Hours

d. Volunteer (unpaid) Coordinator Hours

e. SHIP-Paid Counselor Hours

e. SHIP-Paid Coordinator Hours

f. In-kind Paid Counselor Hours

f. In-kind Paid Coordinator Hours

SECTION 3 - NUMBER OF
OTHER PAID STAFF AND
HOURS

/

State
Office

All Other
Local and TOTAL
Field Sites

SECTION 4 - COUNSELOR TRAININGS

TOTAL

a. # Initial Training(s) for New SHIP Counselors

a. # SHIP-Paid Other Staff

b. # New SHIP Counselors Attending Initial Training(s)

b. # In-kind Paid Other Staff

c. Total # Counselor Hours in Initial Training(s)

c. SHIP-Paid Other Staff Hours

d. # Update Training(s) for SHIP Counselors
e. # SHIP Counselors Attending Update Training(s)

d. In-kind Paid Other Staff Hours

f. Total # Counselor Hours in Update Training(s)

SECTION 5 - NUMBER OF ACTIVE COUNSELORS WITH THE FOLLOWING CHARACTERISTICS
a. Years of SHIP Service:
Less than 1 year
1 year up to 3 years
3 years up to 5 years
Over 5 years
Not collected

c. Disability Status
Disabled
Not disabled
Not collected

b. Age:
Less than 65 years of age
65 years or older
Not collected

d. Gender
Female
Male
Not collected

e. Race/Ethnicity:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White, Not of Hispanic origin
Other
Not Collected

SECTION 6 - WEB-SITE VISITORS (if applicable)
Total # of visits/visitors to web-site during the 2 quarters comprising the 6-month report period:
1st Quarter __________ 2nd Quarter __________
SECTION 7 - DID YOU WORK WITH ANY PARTNERS IN PROVIDING ANY SHIP SERVICES? Yes o

No o

If yes, check the type of partner involvement (check all that apply):
o Training o Counseling o Enrollment/application assistance (e.g. Medicare Prescription Drug Coverage activities)
o Presentations o Outreach o Other
You are encouraged to include details of your partnership involvement in narrative form. Include names of key partnership organizations when possible.
SECTION 8 - ACTIVITIES, LESSONS LEARNED, SIGNIFICANT EVENTS
(Briefly describe on separate sheets. This section should address the following four topic areas: outreach (including activities targeted at
underserved populations), information access and dissemination, training, and partnerships and networking.)
Form CMS-10028-C (0705)