Community Benefit Reporting Form

The Community Benefit information reported through this Web site is used for several reports that the Health System prepares for reporting our contributions to the community.  Some of these reports ask for very detailed information about our community benefit programs, and we are trying to improve our data collection efforts so that we can accurately report our contributions.  We encourage you to use this form to provide us with detailed information about your activities.

It is possible, and you are encouraged to submit several forms for the same community program if the program consists of various different types of activities.  For example, a department or program should submit:

Submitting several forms will provide us with more detailed information about each type of activity.  If you are submitting various forms, please avoid double-counting activities, expenses or revenues by allocating these data as appropriately as possible.

Some programs or departments have identified contact persons to coordinate their submissions.  Please look at the list of Program Contacts (xls) to identify the contact person for your area.  You may want to contact this person before submitting to make sure that reports are not being duplicated.

Questions?
Please refer to our Community Benefit Glossary for help with the terms used in our form.  Any other questions related to reporting Community Benefits can be directed to the Community Benefit Committee through our email address communitybenefit@umich.edu.

Name:
Email: (Required field)
Phone:
Department:
 
Fiscal Year in which program was delivered FY07 FY08
Name of Community Benefit Program
Program Description:
Number of programs or activities (if applicable) during the fiscal year being reported (i.e. number of BP screenings)
Number of persons served
Primary Source of Internal U-M Funding

Please select all that apply from the following options

Hospital

Medical School

Center (such as CVC, CCC, Depression Center)

Clinical Department

Other

If Other please specify

Financial Data:

Commodity Expenses (non-payroll, controllable expenses such as travel, office supplies, food, etc):

Volunteer Hours (Indicate the number of hours volunteered by non-UMHS Faculty and Staff):

Payroll Hours (Indicate the number of hours contributed by type of staff: Physician, Professional, Support Staff):


Donated Medical Procedures, Tests and Supplies( Report donated medical procedures, tests and supplies):

Offsetting Revenue (Indicate revenues received through external grants, insurance payments, fees and donations):
Did this program serve an identified community need? : Yes No
Was this program provided in partnership with another organization? : Yes No
What % of this activity would you estimate benefits Washtenaw County residents?
 

The Community Benefit Committee would like to hear about the impact that your program makes in the community.  If you have a special story that illustrates your program’s contribution to the community enter it here.  We will review these stories and select some to be featured on our Web site