SIRS Team Member

		SIRS TEAM MEMBER FORM
* Items marked with asterisk (*) indicate required fields
Team Member Name
First Name*: Last Name*:		Middle Initial: Nickname:
Team Member Contact Information
Primary Phone Number*: Address: Primary Phone Number Extension: City: Secondary Phone Number: Zip Code: Secondary Phone Number Extension: State/Territory*: Email Address: County:
Team Member Details
Start Date*: End Date:		Partner Organization Affiliation*:
Status (Select only one):		Active Retired
Paid Status (Select only one):		In-Kind-Paid SMP-Paid Volunteer
Team Member Demographic I		formation
Race* (Multiple Selections Allowed):		American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander	White Not Collected
Gender* (Select only one):		Female Male Other Not Collected
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
Date of Birth* (MM/DD/YYYY):
Primary Language (Select only one):		English Chinese Korean Russian	Spanish Vietnamese Other

Secondary Language (Select only one):		English Chinese Korean Russian	Spanish Vietnamese Other
English as a Second Language		Yes	No

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Team Member Role Details
Role* (Select only one):	SMP Director State Level Staff Site Manager Site Staff	Team Member SIRS Submitter
Send Login:	Yes	No
Revoke Login:	Yes	No
Username:
eFile ID:
Send eFile ID:	Yes	No
Revoke eFile ID:	Yes	No
Create 1-800 Medicare Unique ID Number*:	Yes	No
Send 1-800 Medicare Unique ID Number:	Yes	No
Status of 1-800 Medicare Unique ID Number:	Active	Inactive
Number of 1-800 Medicare Unique ID:
Attach File 1
Attach File 2
Attach File 3
Attach File 4
Attach File 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 7 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.