DHCS DCR Quarterly Assessment Form (3M) 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 3M forms. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 3. We experience issues remembering or reminding staff to complete 3Ms. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 4. We collect 3Ms outside of the 45 day window and therefore cannot submit the assessment to the DCR. (If yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 5. We have issues collecting 3Ms for discontinuous partners during the time they were away from the program. (If Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 6. We have issues with the Education section on the 3M form. (If, Yes, please explain why.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 7. We experience issues with the Financial Support section of questions on the 3M. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 8. We experience issues with the Legal Issues / Designations section of questions on the 3M. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 9. We experience issues with the Health Status section of questions on the 3M. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 10. We experience issues with the Substance Abuse section of questions on the 3M? (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 11. We experience issues with the Index of Independent Activities of Daily Living for on the Older Adult 3M? (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 12. We experience issues with the Instrumental Activities of Daily Living for on the Older Adult 3M? (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 13. We experience issues with the County Use Questions section of questions on the 3M. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 14. A change in formatting and layout of the 3M form would improve our ability to capture data. (If Yes, please explain) Never Rarely Occasionally Frequently Always Comment OK Question Title * 15. As an XML batch submission County, we have issues when 3Ms are submitted out of order. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Not Applicable (not an XML County) Comment OK Question Title * 16. As an XML batch submission County, we have issues for reestablished partners before 365 days in that the DCR notes 3Ms are missing but will not accept back filled 3Ms. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Not Applicable (not an XML County) Comment OK Question Title * 17. We have issues with an inability to correct information on the 3M form once it is saved. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 18. We have issues with training related to the 3M form. (If Yes, please explain.) Never Rarely Occasionally Frequently Always Comment OK Question Title * 19. We believe that some of the questions are not useful and should be removed from the 3M form. (If Yes, please note specifically which questions for which age groups should be removed, in your opinion.) Yes No Comment OK Question Title * 20. We have other thoughts about how data quality could be improved related to the 3M Form. Please explain. OK DONE