Sustainability Assessment Sites

Title X Outreach and Enrollment (O/E) Progress Report

INSTRUCTIONS

Dear Title X Service Site, 

Welcome to the 2014­2015 OPA Enrollment Assistance Data Collection Survey. You will be asked to report on 
enrollment efforts that you've conducted at your site between April 1, 2014 and March 31, 2015.  

This survey is collecting site­level data. You should be reporting data for 1 service site per survey form.  

If your answer to a particular question is zero, please enter "0" into the field. Do not leave blank. 

If you have questions, please reach out to your primary Title X grantee. They may facilitate communications with OPA. 

Thank you for your efforts in conducting these essential public health activities. 

Office of Population Affairs (OPA) 

Form Information: 
OMB No. 0990­0423, expires 8/30/2017 

The time required to complete this information collection is estimated to average 1 hour 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 any comments concerning the accuracy of the time estimate or suggestions for improving this 
form, please write to: U.S. Department of Health and Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., 
Suite 336­E, Washington, D.C., 20201, Attn: PRA Reports Clearance Officer. 

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Title X Outreach and Enrollment (O/E) Progress Report
Demographics

*1. Name of service site for which you are reporting data (Note: A service site is the

individual clinic or center; each service site should submit their own form)

*2. City where the service site for which you are reporting data is located

*3. State in which service site for which you are reporting data is located
6  

*4. Name of Grantee from which this service site receives the Title X funding
6  

*5. What is YOUR information, in case we need to contact you about the data reported for

this service site?
Name:
Company:
Email Address:
Phone Number:

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Title X Outreach and Enrollment (O/E) Progress Report
Outreach and Enrollment Assistance Workers

1a. Title X outreach and enrollment assistance workers are any grantee, subrecipient, or service site staff, contractors, or 
volunteer assistance personnel who are trained to facilitate enrollment of individuals into the health insurance 
marketplace, Medicaid, and/or CHIP. 

*6. 1a. Number of outreach and enrollment assistance workers who have successfully

completed ALL required federal and/or state training

*7. 1a. Number of outreach and enrollment assistance workers who have successfully

completed all required federal and/or state training FOR FULL MEDICAID ONLY

*8. 1a. Number of outreach and enrollment workers who have successfully completed all

required federal and/or state training FOR PARTIAL MEDICAID PROGRAMS (ex: Family
Planning Waiver Program)

*9. 1a. Number of outreach and enrollment assistance workers who have successfully

completed all required federal and/or state training FOR OTHER STATE SPECIAL
PROGRAMS

*10. 1a. Number of outreach and enrollment assistance workers who have successfully

completed all required federal and/or state training FOR THE HEALTH INSURANCE
MARKETPLACE

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Title X Outreach and Enrollment (O/E) Progress Report
Outreach and Enrollment Assistance Provided

1b. This should include in­person education about affordable insurance coverage options (one­on­one 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). 

*11. 1b. Number of individuals assisted by a trained outreach and enrollment assistance

worker (Total)

12. 1b. Number of individuals assisted by a trained outreach and enrollment assistance
worker FOR MEDICAID ONLY (Optional)

13. 1b. Number of individuals assisted by a trained outreach and enrollment assistance
worker FOR PARTIAL MEDICAID ONLY (FAMILY PLANNING WAIVER PROGRAM OR SPA)
(Optional)

14. 1b. Number of individuals assisted by a trained outreach and enrollment assistance
worker FOR THE HEALTH INSURANCE MARKETPLACE ONLY (Optional)

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Title X Outreach and Enrollment (O/E) Progress Report
Eligibility Determinations Provided

1c. 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 health insurance marketplace. 

*15. 1c. Number of individuals who received an eligibility determination with the

assistance of a trained outreach and enrollment assistance worker FOR THE HEALTH
INSURANCE MARKETPLACE, MEDICAID, CHIP, FP WAIVER, State Planned Amendment
(SPA), or other health insurance plan (Total)

16. 1c. Number of individuals who received an eligibility determination with the assistance
of a trained outreach and enrollment assistance worker FOR MEDICAID ONLY (Optional)

17. 1c. Number of individuals who received an eligibility determination with the assistance
of a trained outreach and enrollment assistance worker FOR PARTIAL MEDICAID ONLY
(FAMILY PLANNING WAIVER OR SPA) (Optional)

18. 1c. Number of individuals who received an eligibility determination with the assistance
of a trained outreach and enrollment assistance worker FOR THE HEALTH INSURANCE
MARKETPLACE ONLY (Optional)

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Title X Outreach and Enrollment (O/E) Progress Report
Individuals Enrolled

1d. An individual is considered “enrolled” if they have selected a plan and enrolled in it, regardless of whether or not they 
have paid the premium for the plan yet. 

*19. 1d. Number of individuals who enrolled (with the assistance of a trained outreach

and enrollment assistance worker) IN ANY PLAN (e.g. selected a qualified health plan or
Medicaid/CHIP) (Total)

20. 1d. Number of individuals who enrolled (with the assistance of a trained outreach and
enrollment assistance worker) IN FULL MEDICAID OR OTHER PUBLIC INSURANCE PLAN
(e.g. selected a qualified health plan or Medicaid/CHIP) (Optional)

21. 1d. Number of individuals who enrolled (with the assistance of a trained outreach and
enrollment assistance worker) IN PARTIAL MEDICAID (Optional)

22. 1d. Number of individuals who enrolled (with the assistance of a trained outreach and
enrollment assistance worker) IN A PRIVATE PLAN (e.g. selected a plan purchased in an
exchange/marketplacae or through private insurance) (Optional)

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Title X Outreach and Enrollment (O/E) Progress Report
Narrative Responses

Please provide up to 1/2 page of narrative to describe any major barriers and lessons learned during enrollment efforts. 

*23. Barriers:
Describe any major outreach and enrollment barriers you have encountered
5
6  

*24. 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
5
6  

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