State Health Insurance Assistance Program (SHIP) Public and Media Activity Form

Instructions: This form is for all SHIP Public and Media Activities, both REACH and non-REACH events. Use one form per activity, which can include in-person presentations, booths/exhibits, or media or internet activities. Definitions of each type of activity are provided in the accompanying instructions.

Section 1 - TYPE OF ACTIVITY (Check only one type of activity: A-G)

A.  Interactive presentation to public (formerly educational event)           - In Person           - Video Conference or Satellite broadcast     Estimated Number of Attendees:                 Estimated Numer of people enrolled (if any):

B.  Booth/exhibit at health/senior fair, etc.      Estimated number of people potentially reached:        Estimated number of people enrolled (if any):

C.  Radio Show (not PSA or ad)    Estimated number of people potentially reached:       Number of times this show re-aired (if known):

D.  Website Event          - Web Conference/forum          - Interactive chatroom    Estmated number of people potentially reached:

E.  TV/Cable Show (not PSA or ad)      Estimated number of people potenially reached:       Number of times this show re-aired (if-known):

F.  Enrollment Event      Estimated number of people enrolled:

G.  Other              (e.g. PSA's, targeted informational mailing, newspaper/newsletter articles)     Estimated number of people potentially reached:          Number of times this PSA re-aired/re-printed/etc. (if-known):

Section 2 - Activity Information (Please provide the following information if applicable.)

Date of Activity:   /  / Time of Activity:  Start  Stop If multiple dates:  /  /  through                               /  / Total length of activities across all dates:         hrs  (round to the nearest hour) Event or Group Name:     Location of Event:    Address:    City:    State:    Zip:     County:  Contact Name: Contact Phone: ( )  - Name(s) of Presenter(s):      Type of Presenter(s):      SHIP Staff/Coordinator/Sponsor     SHIP Counselor/Volunteer      Other

Section 3 - Topic Focus (Check all that apply)

Medicare (Parts A and B) Non-Renewal Situation Long Term Care Medigap/Medicare Suppliments Medicare Fraud & Abuse Medicare Perscription Drug Coverage (PDP/MA-PD) Other Perscription Drug Coverage/Assistance Medicare Health Plans QMB/SLMB/QI Other Medicaid General SHIP program information Other (specific health topics - ESRD, diabetes):

Section 4 - Target Audience (Check all that apply)

Medicare beneficiaries and /or pre-enrollees Family member/care giver of Medicare benes. Low Income Low Education Asian/Pacific Islander Eskimo & Aleut Hispanic American Indian African American Disabled Rural Other (please describe, such as professionals):     Contact Information: Vicki Dufrene Health Care Info-SHIIP (225) 219-7731 vdufrene@ldi.state.la.us