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Form Approved |
| CDC Program Office: |
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OMB Control No. XXXX-XXXX |
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Exp. Date: XX/XX/20XX |
| CDC Program POC: |
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| Date completed: |
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Sample Performance Measure Specifications Form |
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Performance Measure Characteristics |
Measurement Specifications |
Data Source Attributes |
Baseline and Target |
| Performance Measure (PM) |
Program Objective/Strategy Statement |
Performance Measure Title |
Population Targeted |
Unit of Measurement |
Numerator |
Denominator |
Frequency of Reporting |
Key Stratifications |
Record Level of Reporting |
Data Source(s) |
Data Source Agency or Owner |
Lag in Reporting |
Baseline |
Baseline Year |
Target |
Target Year |
| PM-1 |
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| PM-2 |
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| PM-3 |
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| PM-4 |
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| PM-5 |
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| PM-6 |
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| PM-7….. |
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Column Header Definitions |
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| Performance Measure Characteristics |
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| Program Objective / Strategy Statement |
A general statement about a program outcome/strategy/output. Note: Multiple performance measures may be used to assess impact of a given outcome/strategy/output |
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| Performance Measure Title |
The fully defined title of the performance measure. |
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| Population Targeted |
The population that the performance measure represents (e.g., tested or served persons only, the general population, subpopulations such as women or youth) |
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| Measurement Specifications |
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| Unit of Measurement |
The unit of measurement or calculation for the performance measure (e.g., number, percentage, rate) |
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| Numerator |
Definition and/or calculation of numerator (if applicable) |
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| Denominator |
Definition and/or calculation of denominator (if applicable) |
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| Frequency of Reporting |
Reporting frequency of performance measure data (e.g., annually, quarterly, monthly) |
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| Key Stratifications |
List the strata of interest for assessing performance within selected substrata (e.g., race/ethnicity, age, gender, facility type etc.) |
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| Record Level of Reporting |
Will data be reported as individual level records/observations (line level data), or are the reported data aggregated in any way? |
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| Data Source Attributes |
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| Data Source(s) |
The source(s) from which the performance measure is derived. If more than one data source is used to calculate the performance measure, note here. |
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| Data Source Agency or Owner |
The organization or agency that manages the data source(s) and is responsible for constructing the database and reporting data to the awardee |
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| Lag in Reporting |
The time interval between when the data are collected and when the data are reported to CDC |
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| Performance Measure Baselines and Targets |
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| Baseline |
The initial point estimate of the performance measure |
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| Baseline Year |
The year for the baseline estimate |
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| Target |
The expected improvement in the performance measure estimate and a set date in the future |
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| Target Year |
The reported point estimates (and time period) of the performance measure data |
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| CDC estimates the average public reporting burden for this collection of information as one hour response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX). |
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