Form 1 SMP Outcome Form

Performance Data Collection for SMP Program Outcome

OIGSMPTemplate

Performance Data Collection for SMP Program Outcome Revised

OMB: 0985-0024

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OMB control No. 0985-0024

Shape1 OIG Performance Measures - Site: SMP Working Template


SMP Performance Measures Reporting Period


OUTCOMES


1. Total number of active volunteers


2. Total number of volunteer training hours


3. Total number of volunteer work hours


4. Number of media airings


5. Number of community outreach education events conducted


6. Estimated number of people reached by community outreach education events


7. Number of group education sessions for beneficiaries



8 Number of beneficiaries who attended group education sessions



9. Number of one-on-one counseling sessions held with or on behalf of a

beneficiary


10.

Total number of simple inquiries received


11.

Total number of simple inquiries resolved (percentage of total number received)



12.


Number of complex issues received


13.

A..) Number of complex issues referred for further action


B.) Total dollar amount referred for further action


14. Number of complex issues resolved


15. Number of complex issues pending further action


16. Cost avoidance on behalf of Medicare, Medicaid, Beneficiary, or Other


  1. Actual Medicare funds recovered attributable to the project


  1. Actual Medicaid funds recovered attributable to the project


17.


  1. Actual Savings to beneficiaries attributable to the project


  1. Other savings attributable to the project (e.g. supplemental insurance)







According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0985-0024. The time required to complete this information collection is estimated to average 276 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, Administration for Community Living, Attention: Reports Clearance Officer Room 5203, 1 Massachusetts Avenue, NW, Washington, DC 20001.












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