SMP COMMUNITY EDUCATIONTRACKING FORM

Although this form contains a complete list of types of outreach, it should only be used for one activity at a time.

Name of Person Completing the Form______

TYPE OF OUTREACH ACTIVITY: (Check Only One)

Community Outreach Event / Group Education / Media /  One on One Counseling /  Dissemination

COMPLETE THE FOLLOWING QUESTIONS FOR ALL OUTREACH EVENTS:

Date of Activity: / County:
Time Spent on Event
(Minutes) / Preparation Time:
(Minutes) / Travel Time:
(Minutes)
Name of Person Conducting Event:

Coverage (Select One):

 Local /  Regional /  Statewide /  National /  Multi-State

Form of Contact: (Check One)

 Electronic /  In Person /  E Mail /  Teleconference
 Mail /  Webinar /  Fax /  Phone

Primary & Secondary Topics: (Select Up To Two)

 General Medicare /  Social Security /  IDTheft /  DME
 Fraud, Errors & Abuse /  Medigap/Supplemental /  Medicaid /  Volunteer Recruitment
 Medicare Advantage /  Quality of Care /  Other (Describe) /  Part D
 Military Health Benefits (TRICARE/VA) /  Enrollment, Eligibility, Benefits

1. COMMUNITY OUTREACH/EDUCATION EVENT

Number of People Reached: / Name of Event:

Note: Only those individuals who actually approach your table/group or pick up materials are counted.

Type of Event: (Check One)

 Local/County Fair /  Shopping Center Display /  Health Fair /  Senior Fair
 Library Display /  Conference Meeting /  SeniorCenter Event /  Other

2. GROUP EDUCATIONAL SESSION

Number of People in Attendance: / Name of Event:

Primary & Secondary Audience: (Select Up toTwo)

 Beneficiary /  Insurers/Payors /  Family Member /  Other Professional
 Partner Organization /  Law Enforcement / Caregiver
 Business /  Health Care Providers /  Other

Targeted Beneficiary Population: (Select Only One)

 Disabled /  Rural /  Racial/Ethnic Minority /  Long Term Care Resident
 Homebound /  Native American /  General /  Non-English Speaking
 N/A

3. MEDIA OUTREACH

Media Strategy: (Select One)

 Website /  Newspaper-Op Ed /  Television Interview /  Magazine
 Newsletter Articles, /  Radio Interview /  Television- PSA /  Other (Describe)
 Newspaper, Media Releases /  Radio- PSA /  Newspaper Interview

Number of Airings:______

4. ONE ON ONE COUNSELING

Targeted Beneficiary Population: (Select One)

 Disabled /  Rural /  Racial/Ethnic Minority
 Homebound /  Native American /  General
 Long Term Care Resident /  Non-English Speaking /  N/A

5. DISSEMINATION

Type of Materials Disseminated: (Select One)

 Brochures /  Fact/Tip Sheets /  Flyers
 Personal Health Care Journals /  Promotional Items with SMP Logo (Explain) /  Toolkits
 Other (Explain)

Organization Or Location: (Select One)

 Faith-Based Organizations /  Government Agency /  Library
 Non-Profit Organization /  Private Business /  Private Individuals
 Senior Center/Community Center /  Senior Housing /  Other

Number of Materials Disseminated:______

Dissemination Activity Initiated By:

 SMP /  Recipient

Targeted Beneficiary Population: (Select One)

 Disabled /  Rural /  Racial/Ethnic Minority
 Homebound /  Native American /  General
 Long Term Care Resident /  Non-English Speaking /  N/A

Notes: (Applicable to all Outreach Activities)