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Form Approved |
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OMB Control No. XXXX-XXXX |
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Exp. Date: XX/XX/20XX |
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| Sample Performance Measure Reporting Form |
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Performance Measure Reporting |
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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 |
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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 |
| 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 |
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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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