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.