Stars Goe

STARS GROUP 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 Event * (select only one): Booth/Exhibit (Health Fair, Senior Fair or Community Event) Enrollment Event Interactive Presentation to Public (In-Person, Video Conference, Web-based Event, Teleconference)							Delivery Method (select only one): In-person Web-based Hybrid (in-person and web-based)
Number of Attendees *: __________________
Event Location *
State of Event * : __________________ Zip Code of Event * : __________________ County of Event * : _____________________________________
Event Contact Information
Event Contact First Name: ____________________________________________________ Event Contact Last Name: ____________________________________________________							Event Contact Phone: ____________________________________________________ Event 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
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Special Use Fields

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Field 2: ________________________________

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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.