State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report

Instructions for Completing the
Public and Media Activity Form for the
State Health Insurance Assistance Program (SHIP)
Submitted to CMS Quarterly
Use this revised Public and Media Activity Form for all public education and media activities conducted by your
SHIP program.
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 for the Public and
Media Activity (PAM) Form, including the time to review instructions, search existing data
resources, and 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.

SECTION 1–Type of Activity
If a SHIP counselor or coordinator works directly with a beneficiary, during or after a Public and Media Activity
Event, to assist him or her with an enrollment or provide other substantial one-on-one assistance, two data
elements should be collected:
• a client contact form should be completed to collect as much information as possible about that counseling
contact, AND
• if the SHIP counselor assisted with an enrollment, that person should be included in the aggregate count for
“Estimate # of people enrolled” data field in the section of the PAM form for that event.
Please Check only ONE type of activity.

A.

Interactive Presentation to Public
An interactive forum, speaking engagement, or seminar during which substantive knowledge on
Medicare or the SHIP program is transferred by oral and visual means from a SHIP presenter to those
persons attending the presentation. Includes in-person presentations, video teleconferences, or satellite
broadcasts. Do NOT include SHIP counselor trainings, which should be reported on the SHIP Resource
Report Form. Estimate the number of attendees by using sign-in sheets or by taking a rough head count
of the number of people at the presentation. In addition, if you assisted any attendees with enrollment in
a Medicare Prescription Drug Coverage Plan (PDP/MA-PD), estimate the number of people potentially
enrolled and complete Client Contact Forms.

SHIP Public and Media Activity Form Instructions
12/06

1

B.

Booth/Exhibit
Any event where general/program information and/or simple printed fact sheets are shared with or
distributed to the public. The purpose of SHIP program participation in such events is to inform the
public about the availability of SHIP services in their area. For example, some SHIP programs attend
health or senior fairs or set up information booths in shopping centers in order to increase that
community’s awareness of their services and the need for individual counseling. Estimate the number of
people potentially reached by using a tick-mark for each person that approaches your booth to take
materials and/or speak with a SHIP representative or by counting the number of brochures/materials
distributed. In addition, if you assisted any attendees with enrollment in a Medicare Prescription Drug
Coverage Plan (PDP/MA-PD), estimate the number of people potentially enrolled and complete Client
Contact Forms.

C.

Radio Show (not a PSA or ad)
Radio events can be live or taped. Report the date(s) you are aware the event was originally aired in
Section 2. Estimate the number of people potentially reached for the original show only such as
estimated audience size or potential number of listeners. Indicate, if known, the number of times the
show was re-aired.

D.

Web-Site Event
Includes one-time or limited time interactive events sponsored by your SHIP such as web conferences or
forums, and interactive ‘chatrooms’. Visitors to other parts of your web-site should be reported on the
SHIP Resource Report Form. Estimate the number of people potentially reached by estimating the
number of visitors to these activities.

E.

TV/Cable Show (not a PSA or ad)
TV and cable TV shows can be live or taped. Report the date(s) you are aware the event was originally
aired in Section 2. Estimate the number of people potentially reached for the original show only such as
estimated audience size or potential number of viewers. Indicate the number of times, if known, the
show was re-aired.

F.

Enrollment Event (either solely sponsored by a SHIP or sponsored in
partnership with another organization such as Social Security
Administration office or disease organization)
This includes any type of program where enrollment in a Medicare Prescription Drug Coverage Plan
(PDP/MA-PD) is the key objective and where volunteers or staff are on hand to help the beneficiary
submit an application on-line or by paper. In addition, if you assisted any attendees with enrollment in a
Medicare Prescription Drug Coverage Plan (PDP/MA-PD), estimate the number of people potentially
enrolled and complete Client Contact Forms.

SHIP Public and Media Activity Form Instructions
12/06

2

G.

Other
Include Public Service Announcements (PSAs) (either mailed, broadcast on the radio, or aired on
television); targeted informational mailings; and newspaper/newsletter articles. Estimate the number of
people potentially reached for the original airing only such as potential number of listeners/viewers,
number of pieces mailed, or potential number of readers. Indicate the number of times the PSA was reaired/re-printed/etc.

SHIP Public and Media Activity Form Instructions
12/06

3

SECTION 2–Activity Information
Provide date and time of activity, (for an activity that spans multiple dates, you need only provide the total
length of the activity across all dates), the name of the event and the actual location where the event took place
(not the central office location), person(s) to contact for more information, and names and types of presenters at
the event. For shows/ads that are re-aired, enter the date of the original show only.

SECTION 3–Topic Focus
Check ALL that apply.
If you cover several topics during the course of the event, check all that apply. Topics checked will have
received substantial attention (not just a brief mention).

SECTION 4–Target Audience
Check ALL that apply.
Identify your audience by checking the characteristics that apply.

SHIP Public and Media Activity Form Instructions
12/06

4