CMS-10028-B State Health Insurance Assistance Program (SHIP) Public

OMB No.0938-0850

State Health Insurance Assistance Program (SHIP) Public and Media Activity Form (_ _)
Instructions: This form is for all SHIP Public and Media Activities. Use one form per activity, which can include in-person
presentations, booths/exhibits, media or internet activities. Definitions of each type of activity are provided in the
accompanying instructions.

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

A. Interactive presentation to public
o D. Web-site event
u
u
In-Person
Web conference/forum
u
u
Video teleconference or satellite broadcast
Interactive chatroom
Estimated # of attendees: __________
Estimated # of people potentially reached: __________
o E. TV/cable show (not a PSA or ad)
Estimated # of people enrolled (If any): __________
Estimated # of people potentially reached: __________
o B. Booth/exhibit at health/senior fair, etc.
# times this show re-aired (if known) _____
Estimated # of people potentially reached: __________
o F. Enrollment Event
Estimated # of people enrolled (If any): __________
Estimated # of people enrolled: __________
o G. Other: __________________________
(e.g. PSAs, targeted informational mailing,
o C. Radio show (not a PSA or ad)
newspaper/newsletter articles)
Estimated # of people potentially reached: __________
Estimated # of people potentially reached: __________
# times this show re-aired (if known) _____
# times this PSA re-aired/re-printed/etc. (if known) _____

SECTION 2 - ACTIVITY INFORMATION (Please provide the following information if applicable.)
Date of activity:

_____ / _____ / _____
month /

day /

Event or group name:

year

Time of activity: Start______ Stop_______

Location of event:
Address:

If multiple dates:

_____ / _____ / _____ through

City, State, Zip:

_____ / _____ / _____

County:

Total length of activity across all dates: _____ hrs

Name(s) of Presenter(s):

(round to nearest hour)

Type of Presenter(s):
Contact Name:________________

o SHIP Staff/coordinator/sponsor

Contact Phone:__________________

o SHIP Counselor/volunteer
o Other: ______________________

SECTION 3 - TOPIC FOCUS (Check all that apply)
o Medicare (Parts A and B)
o Non-renewal situation
o Long-Term Care
o Medigap/Medicare Supplements
o Fraud & Abuse
o Medicare Prescription Drug Coverage (PDP/MA-PD)

o
o
o
o
o
o

Other Prescription Drug Coverage/Assistance
Medicare Health Plans
QMB/SLMB/QI
Other Medicaid
General SHIP program information
Other (specific health topics--ESRD, diabetes):

SECTION 4 - TARGET AUDIENCE (Check all that apply)
o Medicare beneficiaries and/or pre-enrollees
o Family members/caregivers of Medicare benes.
o Low-income
o American Indian or Alaska Native
o Asian
o Black or African American

o
o
o
o
o
o

Hispanic or Latino
Native Hawaiian or other Pacific Islander
White, Not of Hispanic origin
Disabled
Rural
Other (please describe, such as professionals):
Form CMS-10028-B (0705)