Click here to enter text. / Click here to enter text. / #
Click here to enter text. / Click here to enter text. / #
Click here to enter text. / Click here to enter text. / #
Activity or event
1 / Interactive presentation to public, face-to-face in-person
Estimated number of attendees / #
Estimated persons provided enrollment assistance / #
2 / Booth or exhibit. At health fair, senior fair, or special event
Estimated number of direct interactions with attendees / #
Estimated persons provided enrollment assistance / #
3 / Dedicated enrollment event sponsored by SHIP or in partnership
Est. # persons reached at event regardless of enroll assistance / #
Estimated # persons provided any enrollment assistance / #
Estimated # provided enrollment assistance with Part D / #
Estimated # provided enrollment assistance with MSP / #
Estimated # provided enrollment assist other Medicare program / #
4 / Radio show, live or taped. Not a Public Service Announcement or ad.
Estimated number of listeners reached / #
5 / TV or cable show, lived or taped. Not a PSA or ad.
Estimated number of viewers reached / #
6 / Electronic other activity: PSAs, electronic ads, crawls, video conf., web conf., web chat
Est. persons viewing/listening activity across entire campaign / #
7 / Print other activity: newspaper, newsletter, pamphlets, etc.
Estimated persons reading print activity across entire campaign / #
Start date / Click here to enter a date. /
End date / Click here to enter a date. /
Event/group name / Click here to enter text.
Contact Information
First name / Click here to enter text.
Last name / Click here to enter text.
Phone number / Click here to enter text.
Event information
County / Click here to enter text.
ZIP code / Click here to enter text.
City / Click here to enter text.
Street address / Click here to enter text.
Topic Focus (check all that apply)
☐ Medicare Parts A and B / ☐ QMB - SLMB - QI / ☐ Other topics: Click here to enter text.
☐ Plan Issues - non-renewal, termination, employer-COBRA / ☐ Other Medicaid
☐ Long-term care / ☐ General SHIP program information
☐ Medigap - Medicare supplements / ☐ Medicare preventive services
☐ Medicare fraud and abuse / ☐ Low-income assistance
☐ Medicare prescription drug coverage - PDP/MAPD / ☐ Dual eligible with mental illness mental disability
☐ Other prescription drug coverage - assistance / ☐ Volunteer recruitment
☐ Medicare Advantage / ☐ Partnership recruitment
Target Audience (check all that apply)
☐ Medicare pre-enrollees - age 45-64 / ☐ Native Hawaiian / ☐ Other Audiences: Click here to enter text.
☐ Medicare beneficiaries / ☐ Guamanian or Chamorro
☐ Family members - caregivers of Medicare beneficiaries / ☐ Samoan
☐ Low-income / ☐ Other Asian
☐ Hispanic, Latino, or Spanish origin / ☐ Other Pacific Islander
☐ White, non-Hispanic / ☐ Some other race/ethnicity
☐ Black or African-American / ☐ Disabled
☐ American Indian or Alaska native / ☐ Rural
☐ Asian Indian / ☐ Employer-related groups
☐ Chinese / ☐ Mental health professionals
☐ Filipino / ☐ Social Work professionals
☐ Japanese / ☐ Dual-eligible groups
☐ Korean / ☐ Partnership outreach
☐ Vietnamese / ☐ Presentations to groups in languages other than English
CMS Special Use Fields / ☒ MIPPA 1 - LIS / ☐ MIPPA 2 - MSP / ☐ MIPPA 3 - LIS & MSP
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