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.  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

«Measure_Name» Character limit: 1900

I.B. Measure Number (auto generated)

«Measure_Number»

I.C. Measure Description

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

«Measure Description» Character limit: 1900

I.D. Measure Owner

«Measure_Owner»  Character limit: 1900

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

«NQF_ID»  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’s National Quality Measures ClearinghouseTM and are available at http://www.qualitymeasures.ahrq.gov/about/hierarchy.aspx:

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.

«Measure_Collection_ Name» 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.

«Measure_Set_ Name» 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.

«Measure_Subset_ Name» 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.

«Measure_Composite_ Name» Character limit: 1900

I.G. Numerator Statement

«Numerator» Character limit: 3800

I.H. Numerator Exclusions (as appropriate)

«Numerator Exclusions» Character limit: 3800

I.I. Denominator Statement

«Denominator» Character limit: 3800

I.J. Denominator Exclusions (as appropriate)

«Denominator Exclusions» 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—Health care professional report
4. Survey—Parent/caregiver report
5. Survey—Child report
6.   Electronic Medical Record
7. Other (If other. please list all other data sources in the field below).

«Other_Data_Sources»

+ Opportunity to upload attachment.

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Page last reviewed December 2013
Internet Citation: Candidate Measure Submission Form (CPCF): CHIPRA Pediatric Quality Measures Program (PQMP). December 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/policymakers/chipra/cpcf-form1.html