MOQA County Users

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* 1. Please select your county.

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* 2. Which data collection option does your county plan to use for collecting MOQA data?

Option 1. Collect MOQA data using eBHS

Option 2. Collect MOQA data using your existing EHR

Option 3. Collect MOQA data manually

My county declines to participate in MOQA at this time

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* 3. What are your county's non-English threshold languages? (Select all that apply)

Arabic

Armenian

Cambodian

Cantonese

Farsi

Hmong

Korean

Mandarin

Other Chinese

Russian

Spanish

Tagalog

Vietnamese

Other (please specify)

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* 4. Please enter your county's primary MOQA contact person. This person is authorized to request changes to your MOQA user licenses and will be included in all MOQA distributions.

Name

Email Address

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* 5. Please enter the name and email address for up to 2 eBHS users for your county. Your county's MOQA contact person can make changes to these users by contacting CIBHS.

User 1 Name

User 1 Email Address

User 2 Name

User 2 Email Address

MOQA County Users

Question Title

* 1. Please select your county.

Question Title

* 2. Which data collection option does your county plan to use for collecting MOQA data?

Question Title

* 3. What are your county's non-English threshold languages? (Select all that apply)

Question Title

* 4. Please enter your county's primary MOQA contact person. This person is authorized to request changes to your MOQA user licenses and will be included in all MOQA distributions.

Question Title

* 5. Please enter the name and email address for up to 2 eBHS users for your county. Your county's MOQA contact person can make changes to these users by contacting CIBHS.

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* 6. Please enter additional email addresses to include on MOQA distribution notices.

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* 7. Please provide any feedback on the MOQA data collection options.