DHCS DCR Partnership Assessment Form Question Title * 1. I work at: Community-based Organization Advocacy Organization California State Agency Technology Vendor Alameda Alpine Amador Berkeley City Butte Calaveras Colusa Contra Costa Del Norte El Dorado Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen Los Angeles Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Orange Placer Plumas Riverside Sacramento San Benito San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Stanislaus Sutter-Yuba Tehama Tri-City Trinity Tulare Tuolumne Ventura Yolo Other (please specify) OK Question Title * 2. We experience issues system timeouts and loss of information while completing PAF forms. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 3. The CSI Number not matching is an issue for me or my organization. Never Rarely Occasionally Frequently Always Comment OK Question Title * 4. The error message for CSI number not matching causes confusion for me or my staff. Never Rarely Ocasionally Frequently Always Comment OK Question Title * 5. We experience issues identifying if a Partner already exists in the system when starting a PAF. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 6. Not being able to change the Partner's birthday or name fields causes issues for me or my staff. Never Rarely Occasionally Frequently Always Comment OK Question Title * 7. We have issues with the "Who referred the partner?" question. (If Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 8. We have issues with the "Provider Number / NPI" question. (If, Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 9. We have issues with the "Full Service Partnership Program ID" question. (If Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 10. We have issues with the "Partnership Service Coordinator ID" question. (If Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 11. We have issues with the "Program Information" questions. (If Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 12. We have issues because the residential settings are not well defined or do not cover all possible options. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 13. The Residential Settings from the "Prior to the last 12 months" are not accurate or useful. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 14. We experience issues with the Education section of questions. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 15. We experience issues with the Employment During the Past 12 Months section of questions. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 16. We experience issues with the Current Employment section of questions. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 17. We experience issues with the Financial Support section of questions. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 18. We experience issues with the Legal Issues / Designations section of questions. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 19. We experience issues with the Health Status section of questions. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 20. We experience issues with the Emergency Intervention section of questions? (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 21. We experience issues with the Substance Abuse section of questions? (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 22. We experience issues with the County Use Questions section of questions. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 23. A change in formatting and layout of the forms would improve our ability to capture data. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 24. As an XML batch submission County, we have issues submitting PAF forms to the DCR. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Not Applicable (not an XML County) Comment OK Question Title * 25. We have other thoughts about how data quality could be improved related to the PAF Form. Please explain. OK Question Title * 26. We have issues with an inability to correct information on the PAF form once it is saved. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 27. We believe that some of the questions are not useful and should be removed from the PAF form. (If Yes, please note specifically which questions for which age groups should be removed, in your opinion.) Yes No Comment OK DONE