NBCCEDP Clinic-Level Data Instrument (Screenshots)

Att 6a - NBCCEDP Clinic Level Data Collection Instruments (screenshots).docx

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Monitoring Activities

NBCCEDP Clinic-Level Data Instrument (Screenshots)

OMB: 0920-1046

Document [docx]
Download: docx | pdf

ATTACHMENT 6a: NBCCEDP Clinic-Level Data Instrument (Screenshots)



Welcome Screen



Menu Bar and Navigation



Health System Data



Health System Data – Baseline





Health System Data – Annual



Clinic Data - Characteristics



Clinic Data – Baseline Breast

Clinic Data – Baseline Breast (continued)

Clinic Data – Baseline Breast (continued)

Clinic Data – Baseline Breast (continued)

** End date above is auto calculated based on start date.

** If rate status is ‘not available’, collect the following field:









Clinic Data – Baseline Breast (continued)

Clinic Data – Baseline Breast (continued)





Clinic Data – Baseline Breast (continued)

Clinic Data – Baseline Breast (continued)





Clinic Data – Annual Breast

** Collect the following if status is ‘terminated’ or ‘suspended’:



Clinic Data – Annual Breast (continued)



Clinic Data – Annual Breast (continued)

Clinic Data – Annual Breast (continued)



Clinic Data – Annual Breast (continued)

** End date above is auto calculated based on start date.

** If rate status is ‘not available’, collect the following field:



Clinic Data – Annual Breast (continued)















Clinic Data – Annual Breast (continued)

Clinic Data – Annual Breast (continued)

** If not in place at PY end, ask the following question:

** If not in place at PY end, ask the following question:





Clinic Data – Annual Breast (continued)

** If not in place at PY end, ask the following question:



** If not in place at PY end, ask the following question:





Clinic Data – Annual Breast (continued)

** If not in place at PY end, ask the following question:



** If not in place at PY end, ask the following question:







Clinic Data – Annual Breast (continued)

** If not in place at PY end, ask the following question:







Clinic Data – Annual Breast (continued)

** If not in place at PY end, ask the following question:



























Clinic Data – Annual Breast (continued)

** If not in place at PY end, ask the following question:

















Clinic Data – Annual Breast (continued)

























Clinic Data – Baseline Cervical

Clinic Data – Baseline Cervical (continued)



Clinic Data – Baseline Cervical (continued)

Clinic Data – Baseline Cervical (continued)

** End date above is auto calculated based on start date.

** If rate status is ‘not available’, collect the following field:









Clinic Data – Baseline Cervical (continued)

Clinic Data – Baseline Cervical (continued)





Clinic Data – Baseline Cervical (continued)

Clinic Data – Baseline Cervical (continued)





Clinic Data – Annual Cervical

** Collect the following if status is ‘terminated’ or ‘suspended’:



Clinic Data – Annual Cervical (continued)



Clinic Data – Annual Cervical (continued)

Clinic Data – Annual Cervical (continued)



Clinic Data – Annual Cervical (continued)

** End date above is auto calculated based on start date.

** If rate status is ‘not available’, collect the following field:



Clinic Data – Annual Cervical (continued)

Clinic Data – Annual Cervical (continued)

Clinic Data – Annual Cervical (continued)



If not in place at PY end, ask the following question:

If not in place at PY end, ask the following question:





Clinic Data – Annual Cervical (continued)



If not in place at PY end, ask the following question:



If not in place at PY end, ask the following question:





Clinic Data – Annual Cervical (continued)



If not in place at PY end, ask the following question:



If not in place at PY end, ask the following question:







Clinic Data – Annual Cervical (continued)



If not in place at PY end, ask the following question:







Clinic Data – Annual Cervical (continued)



If not in place at PY end, ask the following question:

























Clinic Data – Annual Cervical (continued)



If not in place at PY end, ask the following question:















Clinic Data – Annual Cervical (continued)







Page 38 of 38

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHowe, Will (IMS)
File Modified0000-00-00
File Created2022-10-19

© 2024 OMB.report | Privacy Policy