Form CMS-10028 Public and Media Activity Report Form (PAM)

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PUBLIC AND MEDIA EVENTS

OMB No. 0938-0850

Agency Code

Presenter *
Primary Presenter
Second Presenter
Third Presenter
Fourth Presenter
Fifth Presenter
Sixth Presenter

SHIP User ID

First Name

Last Name

Affiliation

Total Hours Spent on Activity

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

Activity or Event

1
Interactive Presentation to Public. Face to Face In-Person.
Estimated Number of Attendees
Estimated Persons Provided Enrollment Assistance

2
Booth or Exhibit. At Heath Fair, Senior Fair, or Special Event.
Estimated Number of Direct Interactions with Attendees
Estimated Persons Provided Enrollment Assistance

3
Dedicated Enrollment Event Sponsored By SHIP or in Partnership.
Est Number Persons Reached at Event Regardless of Enroll Assistance
Estimated Number Persons Provided Any Enrollment Assistance
Estimated Number Provided Enrollment Assistance with Part D
Estimated Number Provided Enrollment Assistance with LIS
Estimated Number Provided Enrollment Assistance with MSP
Estimated Number Provided Enrollment Assist Other Medicare Program

4
Radio Show. Live or Taped. Not a Public Service Announce or Ad.
Estimated Number of Listeners Reached

5
TV or Cable Show. Live or Taped. Not a Public Service Announce or Ad.
Estimated Number of Viewers Reached

6
Electronic Other Activity. PSAs, Electronic Ads, Crawls, Video Conf, Web Conf, Web Chat
Estimated Persons Viewing or Listening to PSA, Electronic Ad,
Crawl Across Entire Campaign, Video Conf, Web Conf, Web Chat

7
Print Other Activity. Newspaper, Newsletter, Pamphlets, Fliers, Posters, Targeted Mailings
Estimated Persons Reading Article, Newsletter, Ad or Pieces of
Targeted Mail or Other Printed Across Entire Campaign

Start Date of Activity
End Date of Activity

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Event or Group Name
Contact First Name - Optional
Contact Last Name - Optional
Contact Phone Number - Optional

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State Code of Event
County Code of Event
ZIP Code of Event
City of Event
Street Address of Event

Topic Focus - Check All That Apply
1 Medicare Parts A and B
2 Plan Issues - Non-Renewal, Termination, Employer-COBRA
3 Long-Term Care
4 Medigap - Medicare Supplements
5 Medicare Fraud and Abuse
6 Medicare Prescription Drug Coverage - PDP / MA-PD
7 Other Prescription Drug Coverage - Assistance
8 Medicare Advantage
9 QMB - SLMB - QI
10 Other Medicaid
11 General SHIP Program Information
12 Medicare Preventive Services
13 Low-Income Assistance
14 Dual Eligible with Mental Illness Mental Disability
15 Volunteer Recruitment
16 Partnership Recruitment
17 Other Topics - Describe:

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Target Audiences - Check All That Apply
1 Medicare Pre-Enrollees - Age 45-64
2 Medicare Beneficiaries
3 Family Members - Caregivers of Medicare Beneficiaries
4 Low-Income
5 Hispanic, Latino, or Spanish Origin
6 White, Non-Hispanic
7 Black, African American
8 American Indian or Alaska Native
9 Asian Indian
10 Chinese
11 Filipino
12 Japanese
13 Korean
14 Vietnamese
15 Native Hawaiian
16 Guamanian or Chamorro
17 Samoan
18 Other Asian
19 Other Pacific Islander
20 Some Other Race-Ethnicity
21 Disabled
22 Rural
23 Employer-Related Groups
24 Mental Health Professionals
25 Social Work Professionals
26 Dual-Eligible Groups
27 Partnership Outreach
28 Presentations to Groups in Languages Other Than English
29 Other Audiences - Describe:

Nationwide and CMS Special Use Fields
01
02
03
04
05
06
07

08

09

10

State and Local Special Use Fields
01
02
03
04
05
06

08

09

10

07

Form CMS-10028B (07/13)

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0850. The time
required to complete this information collection is estimated to average 5 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.