Title X outreach and enrollment sample data collection form

Form Approved

OMB No. 0915-0285

Exp. Date 09/30/2016

Title X (O/E) Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES TITLE X OUTREACH AND ENROLLMENT (O/E) PROGRESS REPORT	FOR OPA USE ONLY
	Grant Number

Grantee Information

Grantee Name, City, State:

Number of Service Sites for which data is reported: ______

O/E Activities		Current reporting period
1a.	Number of O/E assistance workers1 that have successfully completed all required federal and/or state training.
1b.	Number of individuals assisted2 by a trained O/E assistance worker.
1c.	Number of individuals who receive an eligibility determination3 for the Marketplace, Medicaid, or CHIP with the assistance of a trained O/E assistance worker.
1d.	Number of individuals who enroll (e.g., select a qualified health plan or Medicaid/CHIP) with the assistance of a trained O/E assistance worker.

2. Barriers (for the current reporting period only)

Describe any major outreach and enrollment barriers you have encountered.

Required; up to 1500 characters (1/2 page)

3. Key Strategies and Lessons Learned (for the current reporting period only)

Describe key strategies and lessons learned that have contributed to the success of your outreach and enrollment efforts.

Required; up to 1500 characters (1/2 page)

1 Title X outreach and enrollment assistance workers are any grantee, sub recipient or service site staff, contractors, or volunteer assistance personnel who are trained to facilitate enrollment of individuals into the Marketplace, Medicaid and/or CHIP.

2 This should include in-person education about affordable insurance coverage options (one-on-one or small group) and any other assistance provided to facilitate enrollment, e.g., setting up an account, filing affordability assistance information, receiving an eligibility determination, and/or selecting a qualified health plan or Medicaid/CHIP plan.

3 Include all individuals who received an eligibility determination, even if the individual is not determined to be eligible for Medicaid/CHIP or for a subsidy through the Marketplace.

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 0915-0285. The time required to complete this information collection is estimated to average _1_hours/ minutes 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, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer