STARS GOE

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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
(Continued on p.2)


Special Use Fields
Field 1: ________________________________
Field 2: ________________________________
Field 3: ________________________________
Field 4: ________________________________
Field 5: ________________________________
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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.