| CoAg Title: |
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Form Approved |
| CDC Program Office: |
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OMB Control Number: 0920-1282 |
| # of recipients: |
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Expiration Date:01/31/2023 |
| 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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` |
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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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| Public reporting burden of this collection of information is estimated to average XXX hours per response per year (Program to customize), including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1282). |
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