(Private Sector) 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.
Note: 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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0786. The time required to complete this information
collection is estimated to average 1,591 hours per response for all activities, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Baltimore, Maryland 21244-1850

EQR Protocol 5 Attachment A
Survey Tracking Worksheet
September 2012

1

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.
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
September 2012

2