Intervention Details

Details and Output of the Intervention

Name and Contact Information for the Intervention Developer

Funding Source of the Technical Implementation for the Intervention's Development

Description of Value that the Intervention Produces as an Output

Type of Output

Purpose of the Intervention

Intended Use of the Intervention

Intended Patient Population(s) for the Intervention’s Use

Intended User(s)

Intended Decision-Making Role

Cautioned Out-of-Scope Use of the Intervention

Description of Tasks, Situations, or Populations Where Use is Cautioned

Known Risks, Inappropriate Settings, Inappropriate Uses, or Known Limitations

Intervention Development Details and Input Features

Exclusion and Inclusion Criteria that Influenced the Training Data Set

Use of Additional Demographic Variables as Input Features

Description of Demographic Representativeness

Relevance of Training Data to Intended Deployed Setting

Process to Ensure Fairness in Development

Approach to Ensure Fairness

Approaches to Manage, Reduce, or Eliminate Bias

External Validation Process

Description of External Validation Data Source and Environment

Party Conducting the External Testing

Demographic Representativeness of External Data

Description of External Validation Process

Quantitative Measures of Performance

Validity of Intervention in Test Data (Training Data Source)

Fairness in Test Data (Training Data Source)

Validity in External Data

Fairness in External Data

References to Evaluation of Use on Outcomes

Ongoing Maintenance of Intervention Implementation and Use

Process and Frequency of Validity Monitoring

Validity in Local Data

Process and Frequency of Fairness Monitoring

Fairness in Local Data

Update and Continued Validation or Fairness Assessment Schedule

Process and Frequency of Updates

Frequency of Performance Correction