Skip Navigation

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 event, 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 event if the program consists of various different types of activities.  For example, a department, program or individual 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 FY10 FY11
Name of Program, Project or Event
Program, Project or Event Description :
Number of programs, events or activities (if applicable) during the fiscal year (i.e. number of BP screenings)
Number of persons served
Target (Audience, Group or Community) (Check all that apply):
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/Unknown

If Other please specify

Did this program serve an identified community need? Yes No
Was this program, project or event provided in partnership with another organization?

Yes No

Other partnering UMHS Department/Programs



Name of External Community Organization
 

Direct Commodity Expenses

(Please indicate an estimate of the total direct commodity expenses associated with this program/project/event. These are non-payroll controllable expenses, such as travel, office supplies, car seats, immunizations, books or food that are attributable to this program/project/event and would not be expended if the program/project/event did not exist. DO NOT include indirect expenses, these will be calculated)

Direct Expenses:

Purchased Services:

Supplies:

Other Direct Expenses:
(Includes space rental if program is off site)

Paid Staffing Expenses

(This is part of your job/or your department has given paid release time to a staff member to participate in this event/program)

Please Report Hours for:

Nursing Hours:

Clinical Faculty Hours:

House Officer/Trainees Hours:

Administrative/Management Hours:

You may report either hours or actual salary dollars:

Support Staff Hours:

or

Actual Salary Dollars for Support Staff if Known (including benefits) :

Volunteer Staffing Expenses

(List both external community members and UMHS faculty/staff using their own personal time to participate in this event/program.)

Total external community volunteer hours:

and/or

Total UMHS faculty/staff volunteer hours:

Donated Medical Procedures and Test

(Please report different donated medical procedures, tests and supplies and their costs for medical testing used for example during the course of such things as screening examinations, functional evaluations or laboratory tests .)

List procedures/test

Test/Procedure

Cost:

Test/Procedure

Cost:

Test/Procedure

Cost:

 

Offsetting Revenue

(These are revenues received from external grants*, insurance payments, fees and donations as a result of/or in support of the activity/event/program.)

*External grants are funds received from sponsors outside of your department and outside the University.

Fees:

Foundation/Fundraising:

Grants/Support:

Grant Source:

Other Revenue:

 

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