Form 11 SIRS Team Member Form

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

SIRS 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:
Secondary Phone Number Extension:

Zip

Email Address:
Team Member Details

State/Territory*:
Partner Organization Affiliation*:

Start Date*:
End Date:
Status (Select only one):

County:




Paid Status (Select only one):

Code:




Active
Retired
In-Kind-Paid
SMP-Paid
Volunteer

Team Member Demographic Information


Race*
(Multiple Selections Allowed):







Gender* (Select only one):





American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific
Islander
Female
Male
Other
Not Collected




White
Not Collected

Date of Birth*
(MM/DD/YYYY):


Primary Language
(Select only one):






Secondary Language
(Select only one):





English as a Second Language



English
Chinese
Korean
Russian
English
Chinese
Korean
Russian
Yes











Spanish
Vietnamese
American Sign Language
Other
Spanish
Vietnamese
American Sign Language
Other
No

OMB Control Number: 0985-0040 Expiration: Month/Day/2023
Team Member Role Details


Role* (Select only one):





Send Login:
Revoke Login:
Username:
eFile ID:
Send eFile ID:
Revoke eFile ID:
Create 1-800 Medicare
Unique ID Number*:
Send 1-800 Medicare Unique
ID Number:
Status of 1-800 Medicare
Unique ID Number:
Number of 1-800 Medicare
Unique ID:
Attach File 1
Attach File 2
Attach File 3
Attach File 4
Attach File 5




SMP Director
State Level Staff
Site Manager
Site Staff
Yes
Yes







Team Member
SIRS Submitter
No
No





Yes
Yes



No
No



Yes



No



Yes



No



Active



Inactive



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 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.