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* 1. Submitted by:

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* 2. Sponsoring committee (if applicable):

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* 3. Proposed Topic:

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* 4. Category (select all that apply):

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* 5. Do current guidelines exist?

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* 6. Do any performance measures exist?

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* 7. Is there a body of evidence to support the research findings available upon which to base a clinical practice guideline?

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* 8. Briefly describe prevalence, incidence, and socioeconomic burden and if possible, provide the percent of patients who are not currently receiving optimal care:

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* 9. What are three measurable outcomes to determine impact of this topic?

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* 10. Are there current gaps in practice and/or quality improvement activities to address this topic?

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* 11. Please list in bullets or questions the 3 to 5 most pressing aspects of care related to this topic.

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* 12. What other specialties, sub-specialties, patient advocacy groups or stakeholders should be represented on the development panel?

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* 13. Please provide any important selected references:

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* 14. Please identify any organizations that may be interested in collaborating with the development of this topic:

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