| CoAg Title: |
|
|
|
|
| CoAg Number: |
|
|
Form Approved |
| Recipient: |
|
|
OMB Control No. 0920-1282 |
| Reporting Period: |
|
|
Exp. Date: 01/31/2023 |
| Date completed: |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Sample Performance Measure Reporting Form |
|
Performance Measure Reporting |
|
Contextual Data |
Quality Control Assessment |
| Performance Measure (PM) |
Unit of Measurement |
Numerator (Actual) |
Denominator (Actual) |
Point Estimate (Actual) |
Data field(s) needed to help inform or put the PM in context |
Were changes made to PM technical specifications? (Y/N) |
Subjective Data Quality Rating |
Comments for the current reporting period |
| PM-1 |
|
|
|
|
|
|
|
|
| PM-2 |
|
|
|
|
|
|
|
|
| PM-3 |
|
|
|
|
|
|
|
|
| PM-4 |
|
|
|
|
|
|
|
|
| PM-5 |
|
|
|
|
|
|
|
|
| PM-6 |
|
|
|
|
|
|
|
|
| PM-7….. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Column Header Definitions |
| Performance Measure (PM) |
| Performance Measure |
Include the full name of each performance measure defined in the "Performance Measure Specifications Form" |
| Performance Measure Reporting |
| Unit of Measurement |
Note the unit of measurement or calculation for the performance measure (e.g., number, percentage, rate), from the Technical Specification worksheet |
| Numerator (Actual) |
Aggregate number used as the numerator for calculating or reporting on the performance measure |
| Denominator (Actual) |
Aggregate number used as the denominator for calculating or reporting on the performance measure |
| Point Estimate (Actual) |
Point Estimate for the performance measure |
| Key Contextual Data |
| Contextual Data |
Contextual data may be necessary help interpret the performance measure point estimate (examples include underlying population estimates, variation in the availability of medical treatment, changing behavioral patterns, etc.) |
| Quality Control Assessment |
| Changes Made to PM Technical Specifications |
Note whether any changes were made to the performance measure technical specifications. If any changes were made, these should be noted in an addendum to the "Performance Measure Specifications Form" |
| Subjective Data Quality Rating |
Subjective rating of overall data quality 1=poor; 2=fair; 3= average; 4=good; 5=excellent. Subjective ratings of 1, 2 or 3 should be addressed in the comments column |
| Comments |
Note any qualitative or quantitative issues that should be considered in interpretting the reported data |
|
|
|
|
|
|
|
|
|
| Public reporting burden of this collection of information is estimated to average XXX hours per response per year (Program to customize), including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1282). |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|