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.

Section XIV: Identifying Information for the Measure Submitter

Complete information about the person submitting the material, including: 

a)  «Name»,
b)  «Title»,
c)  «Organization»,
d)  «Mailing Address»,
e)  «Telephone Number»,
f)  «Email address», and
g)  Signed written statement guaranteeing that all aspects of the measure will be publicly available, as defined in the Public Disclosure Requirements.

+Opportunity to upload written statement.

Public Disclosure Requirements

Each submission must include a written statement agreeing that, should U.S. Department of Health and Human Services accept the measure for the 2014 and/or 2015 Improved Core Measure Sets, full measure specifications for the accepted measure will be subject to public disclosure (e.g., on the Agency for Healthcare Research and Quality [AHRQ] and/or Centers for Medicare & Medicaid Services [CMS] Web sites), except that potential measure users will not be permitted to use the measure for commercial use.  In addition, AHRQ expects that measures and full measure specifications will be made reasonably available to all interested parties. "Full measure specifications" is defined as all information that any potential measure implementer will need to use and analyze the measure, including use and analysis within an electronic health record or other health information technology.  As used herein, "commercial use" refers to any sale, license or distribution of a measure for commercial gain, or incorporation of a measure into any product or service that is sold, licensed or distributed for commercial gain, even if there is no actual charge for inclusion of the measure. This statement must be signed by an individual authorized to act for any holder of copyright on each submitted measure or instrument. The authority of the signatory to provide such authorization should be described in the letter (Section XIV: Identifying Information for the Measure Submitter).

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Current as of 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-form14.html