Form 4 Group Outreach and Education Form

OMB Control Number 0985-0040 Expires: Month/Date/2023

GROUP 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 Event * (select only one):
 Booth/Exhibit

Number of Attendees *: ___________________

Start Date of Activity *: ___________________

(Health Fair, Senior Fair or Community Event)

 Enrollment

Event

 Interactive

Presentation to Public (In-Person, Video

Conference, Web-based Event, Teleconference)

End Date of Activity: ___________________
Event Location *
State of Event * : __________________

Zip Code of Event * : __________________

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

Event Contact Phone:

____________________________________________________

____________________________________________________

Event Contact Last Name:

Event 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):
 Duals Demonstration
 Medicare Fraud and Abuse
 Extra Help/LIS
 Medicare Part D
 General SHIP Program Information
 Medicare Savings Program
 Long-Term Care Insurance
 Medigap or Supplemental Insurance
 Medicaid
 Original Medicare (Parts A and B)
 Medicare Advantage

(Continued on p.2)





People with Disabilities
Rural Beneficiaries
Other






Rural
N/A
Not Collected
Other








Opioids
Other Prescription Drug Coverage
Partnership Recruitment
Preventive Services
Volunteer Recruitment
Other

OMB Control Number 0985-0040 Expires: Month/Date/2023
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.