0920-1074 CRCCP Clinic Data Collection Instrument

Attachment 5a: CRCCP Clinic-level Data Collection Instrument (Screenshots)

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Health System

Health System (HS) Baseline

Health System (HS) Annual

Clinic Information

Baseline (part 1 – Clinic CRCCP Activity and Status)

Baseline (part 2 – Clinic CRCCP Activity and Status continued)

Baseline (part 3 – Health System and Clinic Characteristics and Clinic Patient Population)

Baseline (part 4 – CRC Screening Rates and Practices)

Baseline (part 5 – CRC Screening Rates and Practices continued)

Baseline (part 6 – CRC Screening Rates and Practices continued)

Baseline (part 7 – Monitoring and Quality Improvement Activities and EBIs and Other Clinic Activities)

Baseline (part 8 – Other Colorectal Cancer Activities and Comments)

Annual (part 1 – Clinic CRCCP Activity and Status)

Annual (part 2 – Clinic CRCCP Activity and Status continued)

Annual (part 3 – Health System and Clinic Characteristics and Clinic Patient Population)

Annual (part 4 – CRC Screening Rates and Practices)

Annual (part 5 – CRC Screening Rates and Practices continued)

Annual (part 6 – CRC Screening Rates and Practices continued)

Annual (part 7 – CRC Screening Rates and Practices continued)

Annual (part 8 – Monitoring and Quality Improvement Activities)

Annual (part 9 – EBIs and Other Clinic Activities)

Annual (part 10 – EBIs and Other Clinic Activities continued)

Annual (part 11 – EBIs and Other Clinic Activities continued)

Annual (part 12 – Annual Implementation Factors)

Annual (part 13 – Other Colorectal Cancer Activities and Comments)

Attachment 5a – Clinic-Level Data Collection Instrument Page 10 of 10