CMS-10028B.Public and Media Activity Report Form - Crosswalk

Attachment B

Changes to the Public and Media Activity Report Form (CMS-10028B)

Current Form

Changes to Form

Reason for Change

TOP OF FORM

Agency Code

For administrative and jurisdictional accountability, since agency authority is not always bound to discrete county and zips

Name(s) of Presenter(s): __________________

Presenter SHIP User ID

Primary Presenter

Second Presenter

Third Presenter

Fourth Presenter

Fifth Presenter

Sixth Presenter

* Can Enter Up To 25 Presenters / Staff Contributors Per Event - Record Any Additional Presenters on Back of Form

Identify SHIP presenters by SHIP User ID. More accurate than identifying by name.

Allow space for up to 6 persons involved in event to record time spent on the event, so as to prevent the generation of duplicate event records (one for each staff).

First Name Last Name Affiliation

Captured only for presenters who are not SHIP users.

Total length of activity across all dates: _____ hrs
(round to nearest hour)

Total Hours Spent on Activity

Allows independent capture of time spent by each person involved.

For up to four persons.

Reworded for clarity.

SECTION 1 - TYPE OF ACTIVITY (Check only one type of activity A-G)

Activity or Event

	A.	Interactive presentation to public
			In-Person
			Video teleconference or satellite broadcast

Interactive Presentation to Public. Face to Face In-Person

Reworded.

Video teleconference very low number of responses. Merged with other options below

Estimated # of attendees: __________

Estimated Number of Attendees

Reworded

Estimated # of people enrolled (if any): _______

Estimated Persons Provided Enrollment Assistance

Reworded for clarity



B.

Booth/exhibit at health/senior fair, etc.

Booth or Exhibit. At Heath Fair, Senior Fair, or Special Event.

Reworded

Estimated # of people potentially reached: __________

Est Number of Direct Interactions with Attendees

Reworded for clarity

Estimated # of people enrolled (if any): _______

Estimated Persons Provided Enrollment Assistance

Reworded for clarity



C.

Radio show (not a PSA or ad)

Radio Show. Live or Taped. Not a Public Service Announce or Ad.

Reworded

Estimated # of people potentially reached: __________

Estimated Number of Listeners Reached

Reworded for clarity

# times this show re-aired (if known) _____

Dropped

Insufficient value, extensive miscoding

	D.	Web-site event
			Web conference/forum
			Interactive chatroom

Dropped

Very low number of responses

Merged with other options below

Estimated # of people potentially reached: __________

Dropped

Very low number of responses

Merged with other options below



E.

TV/cable show (not a PSA or ad)

TV or Cable Show. Live or Taped. Not a Public Service Announce or Ad

Reworded

Estimated # of people potentially reached: __________

Estimated Number of Viewers Reached

Reworded for clarity

# times this show re-aired (if known) ___________

Dropped

Insufficient value, extensive miscoding



F. Enrollment Event

Dedicated Enrollment Event Sponsored By SHIP or in Partnership

Reworded for clarity

Estimated # of people enrolled: _________

Est Persons Reached at Event Regardless of Enroll Assistance

Additional detail and differentiation requested by state SHIPs

Estimated Number Persons Provided Any Enrollment Assistance

Additional detail and differentiation requested by state SHIPs

Estimated Number provided Enrollment Assistance with Part D

Additional detail and differentiation requested by state SHIPs

Estimated Number Provided Enrollment Assistance with LIS

Additional detail and differentiation requested by state SHIPs

Estimated Number Provided Enrollment Assistance with MSP

Additional detail and differentiation requested by state SHIPs

Estimated Number Provided Enrollment Assist Other Medicare Program

Additional detail and differentiation requested by state SHIPs

	F.	Other: __________________________ (e.g. PSAs, targeted informational mailing, newspaper/newsletter articles)

Dropped

Split into two response blocks – Electronic and Printed Media since “Other” was a very large undifferentiated topic of limited usefulness

Estimated # of people potentially reached: __________

Dropped

Split into two options. See below

# times this PSA re-aired/re-printed/etc. (if known) _____

Dropped

Insufficient value, extensive miscoding

Electronic Other Activity. PSAs, Electronic Ads, Crawls, Video Conf, Web Conf, Web Chat

Est Persons Viewing or Listening to PSA, Electronic Ad, Crawl Across Entire Campaign, Video Conf, Web Conf, Web Chat

Electronic part of Other split. Also contains two merged options from above. Persons item reworded for clarity and precision.

Print Other Activity. Newspaper, Newsletter, Pamphlets, Fliers, Posters, Targeted Mailings

Est Persons Reading Article, Newsletter, Ad or Pieces of Targeted Mail or Other Printed Across Entire Campaign

Print part of Other split. Persons item reworded for clarity and precision.

SECTION 2 - ACTIVITY INFORMATION (Please provide the following information if applicable.)

Date of activity: _____ / _____ / _____
		month / day / year

Start Date of Activity

End Date of Activity

Two date fields instead of three date fields is sufficient to capture both concepts. Compare with Multiple Dates below.

If multiple dates: _____ / _____ / _____ through

_____ / _____ / _____

Dropped

See Start Date and End Date item above

Time of activity: Start______ Stop_____

Dropped

Insufficient value.

Total time spent on activity more useful.

Event or group name: _________________

Event or Group Name

Same

Contact Name:________________

Contact First Name - Optional

Contact Last Name – Optional

Reworded. Captured as two fields for sorting etc - Optional

Contact Phone:__________________

Contact Phone Number – Optional

Reworded - Optional

Address: __________________

Street Address of Event

Reworded, captured as two fields – street number and street name for clarity

City, State, Zip: ________________________

City of Event

State Code of Event

ZIP Code of Event

Reworded

Three separate fields

State FIPS code captured not postal code.

County

County Code of Event

Reworded. County FIPS code, not freeform text

Type of Presenter(s):
	SHIP Staff/coordinator/sponsor
	SHIP Counselor/volunteer
	Other: ______________________

Dropped

This info is captured from the presenter’s ship user ID and affiliation above

SECTION 3 - TOPIC FOCUS (Select all that apply)

Topic Focus - Check All That Apply

Reworded

Medicare (Parts A and B)

Medicare Parts A and B

Punctuation

Non-renewal situation

Plan Issues - Non-Renewal, Termination, Employer-COBRA

Reworded for clarity and detail

Long-Term Care

Long-Term Care

Same

Medigap/Medicare Supplements

Medigap - Medicare Supplements

Punctuation

Medicare Fraud & Abuse

Medicare Fraud and Abuse

Punctuation

Medicare Prescription Drug Coverage (PDP/MA-PD)

Medicare Prescription Drug Coverage - PDP / MA-PD

Punctuation

Other Prescription Drug Coverage/Assistance

Other Prescription Drug Coverage - Assistance

Punctuation

Medicare Advantage

Medicare Advantage

Same

QMB/SLMB/QI

QMB - SLMB – QI

Punctuation

Other Medicaid

Other Medicaid

Same

General SHIP program information

General SHIP Program Information

Same

Other (specific health topics--ESRD, diabetes):____________

Dropped

Sufficiently captured in Other Topics – Describe (see below)

Medicare Preventive Services

Additional detail and differentiation requested by state SHIPs

Low-Income Assistance

Additional detail and differentiation requested by state SHIPs

Dual Eligible with Mental Illness Mental Disability

Additional detail and differentiation requested by state SHIPs

Volunteer Recruitment

Additional detail and differentiation requested by state SHIPs

Partnership Recruitment

Additional detail and differentiation requested by state SHIPs

Other Topics - Describe:

Additional detail and differentiation requested by state SHIPs

SECTION 4 - TARGET AUDIENCE (Check all that apply)

Target Audiences - Check All That Apply

Punctuation

Medicare beneficiaries and/or pre-enrollees

Medicare Pre-Enrollees - Age 45-64

Split into two topics. Per request from SHIPs

Medicare Beneficiaries

Split into two topics. Per request from SHIPs

Family members/caregivers of Medicare benes.

Family Members - Caregivers of Medicare Beneficiaries

Reworded

Low-income

Low-Income

Same

American Indian or Alaska Native

American Indian or Alaska Native

Same

Asian

Split into separate categories to match Census

Native Hawaiian or other Pacific Islander

Split into separate categories to match Census

Asian Indian

Split into separate categories to match Census

Chinese

Split into separate categories to match Census

Filipino

Split into separate categories to match Census

Japanese

Split into separate categories to match Census

Korean

Split into separate categories to match Census

Vietnamese

Split into separate categories to match Census

Native Hawaiian

Split into separate categories to match Census

Guamanian or Chamorro

Split into separate categories to match Census

Samoan

Split into separate categories to match Census

Other Asian

Split into separate categories to match Census

Other Pacific Islander

Split into separate categories to match Census

Black or African American

Black, African-American

Reworded to match Census

Hispanic or Latino

Hispanic, Latino, or Spanish Origin

Reworded to match Census

White, Not of Hispanic origin

White, Non-Hispanic

Reworded to match Census

Some Other Race-Ethnicity

Added to match Census

Disabled

Disabled

Same

Rural

Rural

Same

Employer-Related Groups

Additional detail and differentiation requested by state SHIPs

Mental Health Professionals

Additional detail and differentiation requested by state SHIPs

Social Work Professionals

Additional detail and differentiation requested by state SHIPs

Dual-Eligible Groups

Additional detail and differentiation requested by state SHIPs

Partnership Outreach

Additional detail and differentiation requested by state SHIPs

Presentations to Groups in Languages Other Than English

Additional detail and differentiation requested by state SHIPs

Other (please describe, such as professionals): _____________

Other Audiences - Describe:

Reworded

Nationwide and CMS Special Use Fields

10 future use fields for temporary coding of unanticipated mandates (such as DMD) or programs (such as MIPPA). To be defined as needed by CMS.

State and Local Special Use Fields

10 fields to be used at the discretion of states and local agencies for documentation of state-required or state-desired data elements.

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