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Candidate Measure Submission Form (CPCF)

CHIPRA Pediatric Quality Measures Program (PQMP)

The CHIPRA Pediatric Quality Measures Program (PQMP) Candidate Measure Submission Form (CPCF) was approved by the Office of Management and Budget (OMB) in accordance with the Paperwork Reduction Act.聽 The OMB Control Number is 0935-0205 and the Expiration Date is December 31, 2015.

Note: If a section is not applicable to the measure, please write 'Not applicable' in the text field before progressing to the next section.  If the information is not available, please write "Not available" in the text field before progressing to the next section.

  • << >> indicates the name of a text field in the online version of CPCF.
  • + indicates an upload attachment in the online version of CPCF.

Section I. Basic Measure Information

I.A. Measure Name

芦惭别补蝉耻谤别冲狈补尘别禄 Character limit: 1900

I.B. Measure Number (auto generated)

芦惭别补蝉耻谤别冲狈耻尘产别谤禄

I.C. Measure Description

Please provide a non-technical description of the measure that conveys to a broad audience what it measures.

芦Measure Description禄 Character limit: 1900

I.D. Measure Owner

芦惭别补蝉耻谤别冲翱飞苍别谤禄&苍产蝉辫; Character limit: 1900

I.E. National Quality Forum (NQF) ID (if applicable)

芦狈蚕贵冲滨顿禄&苍产蝉辫; Character limit: 1900

I.F. Measure Hierarchy

Please use this section to note if the measure is part of a measure hierarchy or is part of a measure group or composite measure. The following definitions are used by AHRQ鈥檚 National Quality Measures ClearinghouseTM:

I.F.1. Please identify the name of the collection of measures to which the measure belongs (if applicable). A Collection is the highest possible level of the measure hierarchy. A Collection may contain one or more Sets, Subsets, Composites, and/or Individual Measures.

芦Measure_Collection_ Name禄 Character limit: 1900

I.F.2. Please identify the name of the measure set to which the measure belongs (if applicable). A Set is the second level of the hierarchy. A Set may include one or more Subsets, Composites, and/or Individual Measures.

芦Measure_Set_ Name禄 Character limit: 1900

I.F.3. Please identify the name of the subset to which the measure belongs (if applicable). A Subset is the third level of the hierarchy. A Subset may include one or more Composites, and/or Individual Measures.

芦Measure_Subset_ Name禄 Character limit: 1900

I.F.4. Please identify the name of the composite measure to which the measure belongs (if applicable). A Composite is a measure with a score that is an aggregate of scores from other measures. A Composite may include one or more other Composites and/or Individual Measures. Composites may comprise component Measures that can or cannot be used on their own.

芦Measure_Composite_ Name禄 Character limit: 1900

I.G. Numerator Statement

芦狈耻尘别谤补迟辞谤禄 Character limit: 3800

I.H. Numerator Exclusions (as appropriate)

芦Numerator Exclusions禄 Character limit: 3800

I.I. Denominator Statement

芦顿别苍辞尘颈苍补迟辞谤禄 Character limit: 3800

I.J. Denominator Exclusions (as appropriate)

芦Denominator Exclusions禄 Character limit: 3800

I.K Data Sources

Check all the data sources for which the measure is specified and tested.

Data Source [Online form will have radio buttons here]
1. Administrative Data (e.g., claims data)
2.  Paper Medical Record
3. Survey鈥擧ealth care professional report
4. Survey鈥擯arent/caregiver report
5. Survey鈥擟hild report
6.   Electronic Medical Record
7. Other (If other. please list all other data sources in the field below).

芦翱迟丑别谤冲顿补迟补冲厂辞耻谤肠别蝉禄

+ Opportunity to upload attachment.

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Page last reviewed July 2018
Page originally created March 2013

Internet Citation: Candidate Measure Submission Form (CPCF). Content last reviewed July 2018. 大象视频, Rockville, MD.
/policymakers/chipra/cpcf-form1.html

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