Document
STARS MOE
ICR 202310-0985-004 · OMB 0985-0040 · Object 138411401.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | STARS MOE |
| Author | Leslie Green |
| Last Modified By | Writer |
| File Modified | 2023-12-29 |
| File Created | 2026-10-04 |
| Conversion State | complete |
Extracted Text
STARS MEDIA OUTREACH & EDUCATION FORM
* Items marked with asterisk (*) indicate required fields
Start Date of Activity *: __________________ End Date of Activity: __________________
MIPPA Event *:
• Yes
• No
Send to SMP:
• Yes
• No
SIRS eFile ID:
(*required if sending record to SMP)
________________________
Event Details *
Session Conducted By *:
____________________________________________________
Partner Organization Affiliation* : ____________________________________________________
Total Time Spent on Event *:
_____________Hours _____________Minutes
Title of Interaction *:
____________________________________________________
Type of Media * (select only one):
Estimated Number of People Reached: _____________________
• Billboard
• Email
• Magazine
• Newsletter
• Newspaper
• Radio
• Social Media
• Television
• Website
• Other
Geographic Coverage (select only one):
• County or Counties
• Multi-State
• National
• Regional
• Statewide
• Zip Code
Event Location *
State of Event * : __________________ Zip Code of Event * : __________________
County of Event * : _____________________________________
Media Contact Information
Media Contact First Name: ____________________________________________________
Media Contact Last Name: ____________________________________________________
Media Contact Phone:
____________________________________________________
Media Contact Email:
____________________________________________________
Intended Audience * (multiple selections allowed):
• Beneficiaries
• Employer-Related Groups
• Family Members/Caregivers
• Medicare Pre-Enrollees
• Partner Organizations
• Other
Target Beneficiary Group * (multiple selections allowed):
• American Indian or Alaskan Native
• Asian
• Black or African American
• People with Disabilities
• Native Hawaiian or other Pacific Islander
• Hispanic/Latino
• Limited English Proficiency
• Low Income
• LGBTQI+
• Rural
• N/A
• Other
Topics Discussed * (multiple selections allowed):
• Duals Demonstration
• Extra Help/LIS
• General SHIP Program Information
• Long-Term Care Insurance
• Medicaid
• Medicare Advantage
• Medicare Fraud and Abuse
• Medicare Part D
• Medicare Savings Program
• Medigap or Supplemental Insurance
• Original Medicare (Parts A and B)
• Other Prescription Drug Coverage
• Partnership Recruitment
• Preventive Services
• Substance Misuse/Fraud/Abuse
• 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 is estimated to average 4 minutes per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain benefits.