External Quality Review of Medicaid MCOs and Supporting Regulations in 42 CFR 438.360, 438.362, and 438.364

EQR PROTOCOL 5 – VALIDATION AND IMPLEMENTATION OF SURVEYS
ATTACHMENT A: Survey Validation Worksheet for the Initial Three Survey Activities*
Instructions:
For survey administration: Use the worksheet first, to track and document steps performed, and second,
as a detailed index of survey work papers. In the Documentation column, enter the titles of documents
developed or consulted for each activity performed in implementing the survey. In the
Findings/Comments column, provide brief comments about the decisions reached or findings of review
activities.
For survey validation: Use the worksheet to identify the documents reviewed and any related comments
or findings. In the Documentation column, enter the titles of documents reviewed for each activity
performed in validating the survey. In the Findings/Comments column, keep notes about the outcome of
the document review. Use the worksheet as an outline for the final report to the State.
*The worksheet details validation steps for the initial three activities. Additional information for the
remaining five survey validation activities is available throughout Protocol 5. The tool may be expanded
as needed by the External Quality Review Organization.

SURVEY
ELEMENT/ACTIVITY

DOCUMENTATION (List by title
and attach)

FINDINGS/COMMENTS

Activity 1: Survey
purpose(s), objective(s)
and audiences
Written statement of
survey purpose(s) that
addresses access,
timeliness and/or quality
of care.
Unit(s) of analysis is
clearly stated and
includes individual MCOs.
Written study objective
are clear and
measurable.
Audience(s) for and
intended use of survey
findings are identified.
Activity 2: Survey
Instrument
The survey instrument
was tested and found
reliable.

EQR Protocol 5 Attachment A
Survey Tracking Worksheet
December 2011

1

SURVEY
ELEMENT/ACTIVITY

DOCUMENTATION (List by title
and attach)

FINDINGS/COMMENTS

The survey instrument
was tested and found
valid.
Validity and reliability
testing were performed
for the target population
Activity 3: Sampling
The study population is
clearly identified.
The sample frame is
clearly defined, is
appropriate to the survey
objectives, and is free
from bias.
Sampling method is
appropriate to the survey
purpose.
Sample size is sufficient
for the intended use of
the survey.
• Acceptable margin
of error
• Level of certainty
required
Procedures used to
select the sample were
appropriate and protected
against bias.

EQR Protocol 5 Attachment A
Survey Tracking Worksheet
December 2011

2