STARS Team Member

STARS 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 *: _________________________________ Primary Phone Number Extension: ___________ Secondary Phone Number: ________________________________ Secondary Phone Number Extension: ___________ Email Address:_______________________________________							Address: _________________________________________ City: _________________________________________ Zip Code *: _____________________________________ State/Territory *: _________________________________ County *: _________________________________________
Team Member Details
Start Date * : __________________ End Date (if applicable): _________________							Partner Organization Affiliation * (Indicate primary org. that team member is affiliated with): __________________________________________________ __________________________________________________
Status * (Select only one): Active Inactive Retired							Paid Status * (Select all that apply): SHIP In-Kind-Paid SHIP Volunteer SHIP-Paid MIPPA In-Kind-Paid MIPPA Volunteer MIPPA-Paid
Team Member Demographic Information
Race * (Multiple selections allowed):
American Indian or Alaskan Native Asian Black or African American Hispanic or Latino					Native Hawaiian or Other Pacific Islander White Other Not Collected
Date of Birth *: _____________________________________
Team Member Demographic Information (continued)
Primary Language * (Select only one): English American Sign Language Chinese Korean Russian Spanish Vietnamese Other			Secondary Language: (Select only one): English American Sign Language Chinese Korean Russian Spanish Vietnamese Other
Sexual Orientation * Which of the following best represents how you think of yourself? [Select ONE]: Lesbian or gay Straight, that is, not gay or lesbian Bisexual I use a different term ________________________________ Don’t know Prefer not to answer
Gender Identity* What is your current gender? [Select ONE] Female Male Transgender I use a different term ________________________________ Don’t know Prefer not to answer								Gender Identity* Do you consider yourself transgender? [Select ONE] Yes No Prefer not to answer
Team Member STARS Details
Role * (Select only one):
SHIP Assistant Director State Staff Sub-State Manager	Site Manager Sub-State Staff Site Staff								Team Member STARS Submitter
Send Login Credentials:		Yes				No
Revoke Login:		Yes				No
Revoke SHIP eFile ID:		Yes				No
Program * (Multiple selections allowed):		SHIP MIPPA				SMP (Enter SIRS eFile ID, if applicable): _____________________________
Team Member Unique ID Details
Create CMS Unique ID Number *:		Yes		No
Send CMS Unique ID Number:		Yes		No
Status of CMS Unique ID Number * :		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 is estimated to average 5 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.