Form 1 SMP Outcome Form

OMB control No. 0985-0024

Exp. Date XX/XX/2019

_{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

2. Actual Medicaid funds recovered attributable to the project

_17.

3. Actual Savings to beneficiaries attributable to the project

4. 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 138 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, 330 C Street, SW, Washington, DC 20024.