STARS Training Form

STARS TRAINING FORM
* Items marked with asterisk (*) indicate required fields
Training Month *: (MM)
Training Day: (DD)
Training Year *: (YYYY)
Program*:		MIPPA SHIP
Title of Training * :
Part of a Multi-Day Series * :			Yes	No
Delivery Method * (select all that apply):			In Person Online – Self Paced Virtual/Online In Person and Virtual/Online Other
Type of Training * (select only one):			Initial Orientation Update
Submitted by * :
Partner Organization Affiliation:
Training Provider: (Multiple selections allowed)			ACL CMS Medicaid Agency MIPPA Resource Center (NCBOE) Social Security Administration SHIP TA Center SMP Resource Center SHIP/SMP/MIPPA State/Local SHIP Created/Developed Other ACL Resource Center Other National Partner Other Federal Government Partner
Trainer 1 First Name and Last Name:
Trainer 1 Additional Information:
Trainer 2 First Name and Last Name:
Trainer 2 Additional Information:
Number of Attendees * :
Attach Attendee List:
Total Length of Training * :			_______ Hours _______ Minutes

Training Location
Location ZIP Code: _______________________________________________ State / Territory * : _______________________________________________________ County of Training Location: _____________________________________________ Location Address: __________________________________________________________ Location Contact First Name: __________________________________________________ Location Contact Last Name: __________________________________________________ Location Contact Email: ______________________________________________________ Location Contact Phone: ( ______ ) -__________ -____________
Geographic Coverage (select only one):	Municipality County Regional Statewide Not Applicable
Training Topics * (At least one Training Topic selection is required. Multiple selections allowed)
Benefit Topics Coordination of Benefits Duals Demonstration Employer Health Benefits Long-term Care Insurance Marketing Regulations Medicaid Medicare Advantage (MA and MA-PD) Medicare Part D Medicare Plan Finder Medicare Savings Programs Medigap or Medicare Select Original Medicare (Parts A & B) Other Health Insurance Other Prescription Assistance Part D Low Income Subsidy (LIS/Extra Help) Preventive Services Veterans Health Benefits			Administrative Topics CMS Unique ID Confidentiality Complaints Tracking Module Customer Service/Counseling Skills Forms & Reporting MARx Performance Measures Presentation Skills Program Information Program Management Outreach
Special Use Fields
Field 1: _______________ Field 2: _______________ Field 3: _______________ Field 4: _______________		Field 5: _______________ Field 6: _______________ Field 7: _______________ Field 8: _______________
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 6 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.

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