Form 2 Public and Media Events Form

OMB NO. 0985-0040

_{I Agency Code}

PUBLIC AND MEDIA EVENTS

Presenter*	SHIP User ID						First Name	Last Name	Affiliation	Total Hours Spent on Activity
Primary Presenter
Second Presenter
Third Presenter
Fourth Presenter
Fifth Presenter
Sixth Presenter

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

_{IActivity or Event}

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

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

3 IDedicated 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 IRadio Show. Live or Taped. Not a Public Service Announce or Ad. Estimated Number of Listeners Reached I _{I I I I I}

5 jlV or Cable Show. Live or Taped.Not a Public Service Announce or Ad. Estimated Number of Viewers Reached _{I I I I I I}

6 IElectronic 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
	I I I I I I

7 !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
	I I I I I I

E\ent or Group Name
Contact First Name - Optional
Contact Last Name - Optional
Contact Phone Number- Optional	( ) -

State Code of E\tent
County Code of E\tent
ZIP Code of E\tent
City of Event
Street Address of Event

Target Audiences- Check All That Apply
1	Medicare Pre-Enrollees -Age 4
2	Medicare Beneficiaries
3	Family Members - Caregil.ers 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 Nati...e
9	Asian Indian
10	Chinese
11	Filipino
12	Japanese
13	Korean
14	Vietnamese
15	Nati...e 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: I

I

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 Co\erage - PDP I MA-PD
7	Other Prescription Drug Co\erage - Assistance
8	Medicare Advantage
9	QMB- SLMB- Ql
10	Other Medicaid
11	General SHIP Program Information
12	Medicare Pre\enti\€ Services
13	Low-Income Assistance
14	Dual Eligible with Mental Illness Mental Disability
15	Volunteer Recruitment
16	Partnership Recruitment
17	Other Tepics - Describe: I

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 0985-0040. 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: ACL, 330 C St SW, Attn: (OHIC) Office of Healthcare Information Counseling, Washington, DC 20024.