University of Michigan Health System
Community Benefit Event Reporting Form
Please describe below the events, activities or initiatives your department provides that are reportable as
Community Benefit. Save the completed form, then email it to communitybenefit@med.umich.edu. If you need
assistance, email communitybenefit@med.umich.edu. For additional information, visit the UMHS Community
Benefit website at http://www.med.umich.edu/comben/.
Event Overview
Fiscal year event occurred: 2015 (7/1/2014 - 6/30/2015)
Event name:
Describe the event (and add other comments as necessary):
Number of events included in report:
Total persons served:
Pick from list
Event contact:
Phone:
Email:
Department name:
Event Expenses and Revenues
Internal U-M Funding
Select the part of UMHS that provided the primary source of event funds: Hospital / Health Center
If other, please describe:
Pick from list
Direct Expenses
Estimate event expenses excluding staff. Enter amounts in only one column, not both:
OR itemize amounts here. Enter amounts in only one column, not both.
Enter total amount here



Direct expenses: $
Supplies: $
(Example: office supplies)
Purchased services: $
(Example: hiring contractors, buying food)
Other direct expenses: $
(Example: medical procedures, tests)
Paid Staff Hours
Record the number of hours that each type of UMHS
faculty/staff contributed to the event as part of their
employment:
Volunteer Hours
Record the number of hours UMHS faculty/staff
contributed to the event that was not part of their
employment:
Paid Staff type
Clerical / Support staff
Clinical (Physician, Resident)
Nursing / Allied Health
Admin / Management
Volunteer Staff type
Clerical / Support staff
Clinical (Physician, Resident)
Nursing / Allied Health
Admin / Management
Hours
Hours
Revenue
Page 1 of 3 cb
Community Benefit Reporting
3/9/2016
Estimate total revenue generated by the event and/or funds external to UMHS that supported the event:
Event fees: $
Fundraising activities or funds provided by foundations: $
Grant(s): $
Grant source(s):
Other revenue: $
Describe:
Community Needs and Event Specifics
Select the primary health need the event addressed:
If other, describe:
Pick from list
Format
Identify the event format. Check all that apply:
Seminars / classes
Health fairs/screening
Events/meetings
Speakers’ bureau
Newsletter
TV/radio
Clinic
Other Describe:
Setting
Identify the setting(s) where the event took place. Check all that apply:
Inpatient
Outpatient
UMHS Facility
Community
Workplace
Home
Other Describe:
Geographic Location
Identify the location(s) in which the event took place. Check all that apply:
Ann Arbor City/Township
Chelsea, Dexter, Manchester
Saline/Milan
Superior Township
Ypsilanti City/Township
Other Describe:
Page 2 of 3 cb
Community Benefit Reporting
3/9/2016
Groups Reached
Please identify the groups the event reached. Check all that apply:
Target Group
Pick from list
Broader community
Racial, cultural or ethnic minorities
Uninsured/underinsured
Persons with disabilities
LGB
Other Describe:
Age Group
Infants
Children
Teens
Adults
Seniors
All
Gender
All
Collaboration
Check the box if the event was a collaboration/partnership.
 List UMHS Partners:
 List External Partners:
Thank you for completing this report. The Community Benefit team will review your form and may follow up with
you for clarification purposes. If the team modifies your report, they will send you the edited version for your
records.
Page 3 of 3 cb
Community Benefit Reporting
3/9/2016