1. Data Collection Plan Worksheet – <Project name>
Data Type
Source, n
numerator/denominator if %
When collected
By whom
Diagnostic
Data
Outcome
Measure(s)
Baseline
Results
Process
Counterbalance Measures(s)

2. Data Collection Plan - example
Data Collection Plan Worksheet – Time from Surgery to Chemotherapy
Data Type
Source, n
numerator/denominator if %
When collected
By whom
Diagnostic
Data
Checksheets for Reasons
Patient Surveys (20)
1-15 May 2016
Office clerk(init)
Outcome
Measure(s)
Baseline
Patient charts
All new Breast Cancer Patients
1 May-30 June 2016
Nurse (init)
Results
1 July-31 Aug 2016
Nurse(init)
Process
  Patient chart
Time from surgery to date referral received.
 1 May – 30 June 2016
Counterbalance Measures(s)
Patient Experience
1 Jun – 30 Jun 2016
1 Aug – 31 Aug 2016