Form 10 SMP Team Member Form

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

TEAM MEMBER FORM
* Items marked with asterisk (*) indicate required fields

Team Member Name
First Name *: ______________________________

Middle Initial: ______ Last Name *: ______________________________

Nickname: ________________________________

Team Member Contact Information
Primary Phone Number *: _________________________________

Address: _________________________________________

Primary Phone Number Extension: ___________

City:

Secondary Phone Number : ________________________________

Zip Code *: _____________________________________

Secondary Phone Number Extension: ___________

State/Territory *: _________________________________

Email Address:_______________________________________

County *: _________________________________________

_________________________________________

Team Member Details
Partner Organization Affiliation *
(Indicate primary org. that team member is affiliated with):

Start Date * : __________________

__________________________________________________
End Date (if applicable): _________________
__________________________________________________
Status * (Select only one):

Paid Status * (Select only one):
 In-Kind-

 Active

 Inactive

 Retired

 MIPPA

Paid

-Paid

 SHIP-Paid

 Volunteer

Team Member Demographic Information
Race * (Multiple selections allowed):
 American

 Native

Indian or Alaskan Native

Asian
Black

Hawaiian or Other Pacific Islander

 White
 Other

or African American

Hispanic

 Not

or Latino

Collected

Date of Birth *:_____________________________________

Gender * (Select only one):



Female

 Male

 Other



Not Collected

Team Member Demographic Information (continued)
Primary Language *(Select only one):

Secondary Language: (Select only one):



English



English



Chinese



Chinese



Korean



Korean



Russian



Russian



Spanish



Spanish



Vietnamese



American Sign Language



American Sign Language



Vietnamese



Other



Other

Team Member STARS Details
Role * (Select only one):


SHIP Assistant Director



State Staff



Sub-State Manager



Site Manager



Team Member



Sub-State Staff



STARS Submitter



Site Staff

Send Login Credentials:

 Yes

 No

Revoke Login:

 Yes

 No

 SHIP

 SMP

Program * (Multiple selections allowed):

 MIPPA

(Enter SIRS eFile ID, if applicable):

_____________________________

Team Member Unique ID Details
Create 1-800 Medicare Unique ID Number *:

 Yes

 No

Send 1-800 Medicare Unique ID Number:

 Yes

 No

Status of 1-800-Medicare Unique ID Number * :



 Inactive

Notes

Active

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 5 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.