Form 2 Media Outreach Education Form

OMB Control Number 0985-0040 Expiration: Month/Day/2023

MEDIA OUTREACH & EDUCATION FORM
* Items marked with asterisk (*) indicate required fields
 Yes
 No
MIPPA Event *:
SIRS eFile ID:
 Yes
 No
________________________
Send to SMP:
(*required if sending record to SMP)
Event Details *
Session Conducted By *:
Partner Organization Affiliation* :
____________________________________________________

____________________________________________________

Total Time Spent on Event *:

Title of Interaction *:

_____________Hours

_____________Minutes

Type of Media * (select only one):

____________________________________________________
Estimated Number of People Reached: _____________________

 Billboard

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Radio

 Email

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Social Media

 Magazine

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Television

 Newsletter



Website

 Newspaper

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Other

Geographic Coverage (select only one):

Start Date of Activity *: ___________________



County or Counties



Regional



Multi-State



Statewide

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National

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Zip Code

End Date of Activity: ___________________

Event Location *
State of Event * : __________________

Zip Code of Event * : __________________

County of Event * : _____________________________________
Media Contact Information
Media Contact First Name:

Media Contact Phone:

____________________________________________________

____________________________________________________

Media Contact Last Name:

Media Contact Email:

____________________________________________________

____________________________________________________

Intended Audience * (multiple selections allowed):
 Beneficiaries
 Limited-English Proficiency
 Employer-Related Groups
 Medicare Pre-Enrollees
 Family Members/Caregivers
 Partner Organizations
Target Beneficiary Group * (multiple selections allowed):
 American Indian or Alaskan Native
 Hispanic/Latino
 Asian
 Languages Other Than English
 Black or African American
 Low Income
 Disabled
 Native Hawaiian or other Pacific
Islander
Topics Discussed * (multiple selections allowed):

 People with Disabilities
 Rural Beneficiaries
 Other

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



Rural
N/A
Not Collected
Other

OMB Control Number 0985-0040 Expiration: Month/Day/2023

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Duals Demonstration
Extra Help/LIS
General SHIP Program Information
Long-Term Care Insurance
Medicaid
Medicare Advantage

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Medicare Fraud and Abuse
Medicare Part D
Medicare Savings Program
Medigap or Supplemental Insurance
Opioids
Original Medicare (Parts A and B)

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Other Prescription Drug Coverage
Partnership Recruitment
Preventive Services
Volunteer Recruitment
Other

(Continued on p.2)
Special Use Fields
Field 1: ________________________________
Field 2: ________________________________
Field 3: ________________________________
Field 4: ________________________________
Field 5: ________________________________
Notes

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number (OMB 0985-0040). Public reporting burden for this collection of information
averages 4 minutes per response, including time for gathering, maintaining, completing and reviewing the collection of information.
The obligation to respond to this collection is required to retain or maintain benefits under the statutory authority from Section 4360(f)
of the OBRA.