Quality Measure Report Request
Request Type:
New Report
Revision to Report
Revision to Report
Note:
Only authorized personal may request reports. If you are unsure, please email
[email protected]
to see if you qualify.
Requested by (name):
Key Contact (name):
Department:
Phone Number:
System the report is to be run from:
Date needed*:
MM slash DD slash YYYY
*Note:
Reports generally take 5-7 business days to process and be built. We will try our best to
accommodate the date provided.
Please provide the intent of the report:
Please provide what is expected from the report (Please explain thoroughly. This allows us to better understand what is being requested):
Please list the quality measure:
Date range for data (i.e. previous month, year to date, last 2 years, etc.)
How often does the report need to be run?
Once
Weekly
Monthly
Quarterly
Yearly
If not one time, specify when report is to be run (i.e. first Monday or last day of the month):
If this report is going to an Athena report inbox, please list who is to receive the report (first and last name):
EHR Team Only
Received on:
Assigned to:
Date
MM slash DD slash YYYY
EHR Approval:
Submitter
(Required)
Please enter your name
QA by: