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Brief: Substance use prevention

Prepared from Grant Precedent, 2026-10-23; data as of precedent 2026-10-21, measures 2026-10-22.

Measures funders require

Centers for Disease Control and Prevention (U.S. Department of Health and Human Services), Drug-Free Communities (DFC) Support Program

Past 30-day use

Perception of risk

Perception of parental disapproval

Perception of peer disapproval

Annual progress report: community profile, sector and youth engagement, coalition capacity, risk and protective factors, and youth substance use prevention strategies

Short-term, intermediate and long-term outcome measures identified by the recipient from its program logic model

Office of Juvenile Justice and Delinquency Prevention (DOJ OJP), Community and Schools Youth Drug Prevention Program

During this reporting period, how many unique youth received interventions to increase their knowledge of drug prevention?

  • Code: Q1
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of interventions they may have been involved in. Youth refer to children and adolescents under the age of 18. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

During this reporting period, how many unique youth received treatment, services, or support for exposure to violence or adverse experiences?

  • Code: Q2
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of services they may have been involved in. Youth refer to children and adolescents under the age of 18. Exposure to violence refers to direct or indirect exposure to violence in the home, school, or community. Adverse experiences are stressful or traumatic events during childhood (0-17 years) that disrupt a child's safety, stability, and bonding, including abuse, neglect, violence, loss, and household dysfunction like substance abuse or mental health issues.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

During this reporting period, how many unique youth engaged in extracurricular activities, after- school programs, or mentoring programs?

  • Code: Q3
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of activities or programs they may have been involved in. Youth refer to children and adolescents under the age of 18. Extracurricular activities are voluntary pursuits outside a student's regular academic schedule, encompassing sports, clubs (academic, arts, STEM), arts, community service, and employment. These activities are designed to foster personal growth, skill development (such as teamwork, leadership, or time management), and exploration of interests beyond core subjects, often complementing classroom learning. Mentoring provides structured relationships where individuals guide and support the personal growth of others. These services facilitate skill transfer, career development, and the building of confidence by fostering supportive, trusted relationships through which mentors share knowledge and insights to help mentees reach their full potential.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

During this reporting period, how many unique parents or caregivers received interventions to increase their knowledge of drug prevention?

  • Code: Q4
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of interventions they may have been involved in. Parent is defined as a child’s or adolescent's biological parent, adoptive parent, foster parent or stepparent through marriage. Caregiver means an individual, including a relative, neighbor, or family friend, who regularly or frequently provides care, with or without compensation, for a child or adolescent for whom the individual is not the parent. This individual may also be designated as a temporary adult caregiver. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

During this reporting period, how many unique individuals engaged in community coalitions to reduce drug use?

  • Code: Q5
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of coalitions they may have been involved in. Individuals in this context refer to community members and employees or volunteers at schools, community-based organizations, or health systems and can also include clinicians, policymakers, and law enforcement. Community coalitions are groups of individuals and organizations (such as residents, businesses, non-profits, or the government) working together with shared resources and expertise to achieve common goals. In this context the goal is reducing drug use.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

During this reporting period, how many unique law enforcement officers and personnel engaged in community coalitions to reduce drug use?

  • Code: Q6
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of coalitions they may have been involved in. Law enforcement officers and personnel means police officers, employees, volunteers, and police departments. Community coalitions are groups of individuals and organizations (such as residents, businesses, non-profits, or the government) working together with shared resources and expertise to achieve common goals. In this context the goal is reducing drug use.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

During this reporting period, how many unique service providers were involved in screening youth to determine their needs or provide interventions to meet their needs?

  • Code: Q7
  • Requirement: required
  • Definition: Reporting period refers to the specific timeframe covered by this report. Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of screenings they may have been involved in. Service providers are people who work or volunteer in organizations that provide services in support of drug prevention. Screening is a formal process of using specific tools and procedures to assess the treatment or support services needs of individuals. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Did you adjust the program plan as described in your application’s proposal narrative? If yes, what adjustments did you make, and why?

Did you experience any challenges during this reporting period that impacted service delivery to program participants? If yes, how did you address the challenges, and do the challenges remain unresolved?

Did you engage with OJJDP training and technical assistance providers during this reporting period? If yes, did the providers adequately address your issue?

Of the unique youth who received an intervention to increase drug prevention knowledge during this reporting period, how many perceived a high risk of harm associated with drug use?

  • Code: Q11
  • Requirement: required
  • Definition: Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of interventions they may have been involved in. Youth refer to children and adolescents under the age of 18. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part. Reporting period refers to the specific timeframe covered by this report. Perceiving a high risk of harm is a common indicator for intervention effectiveness and is typically measured using self-report approaches.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Of the unique youth who received any intervention during this reporting period, how many perceived a high risk of harm associated with drug use?

  • Code: Q12
  • Requirement: required
  • Definition: Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of interventions they may have been involved in. Youth refer to children and adolescents under the age of 18. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part. Reporting period refers to the specific timeframe covered by this report. Perceiving a high risk of harm is a common indicator for intervention effectiveness and is typically measured using self-report approaches.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Of the unique youth who received an intervention to increase drug prevention knowledge during this reporting period, how many expressed an intent to abstain from drugs?

  • Code: Q13
  • Requirement: required
  • Definition: Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of interventions they may have been involved in. Youth refer to children and adolescents under the age of 18. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part. Reporting period refers to the specific timeframe covered by this report. Intent to abstain from drug use is a common indicator for intervention effectiveness and is typically measured using self- report approaches.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Of the unique youth who received an intervention to increase drug prevention knowledge since the start of this award, how many self-reported substance use within the past 30 days?

  • Code: Q14
  • Requirement: required
  • Definition: Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of interventions they may have been involved in. Youth refer to children and adolescents under the age of 18. Interventions or programs refer to specific sets of activities that are carried out by the award recipient and supported by OJJDP award funds, in whole or in part.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Did the program experience any challenges related to external factors beyond your control during the reporting period that impacted program outcomes? If yes, please describe the challenges.

How would you describe progress made toward this award's goals and objectives during this reporting period?

What services are supported, in whole or in part, by OJJDP’s grant funds? Select all that apply.

  • Code: Q1
  • Requirement: required
  • Definition: Answer options: o Drug prevention education o Extracurricular activities o Mentorship programs o Screenings for treatment and support services needs o Treatment and support services delivery o Referrals to treatment and support services o Trauma-informed support services o Parent and caregiver skills and family relationship programs o Community-level programs and coalitions o Other, specify: ____ Drug prevention education teaches individuals, often students, the skills and knowledge to avoid starting or misusing drugs, alcohol, and tobacco, focusing on resisting peer pressure, understanding risks, and making healthy choices. Extracurricular activities are voluntary pursuits outside a student's regular academic schedule, encompassing sports, clubs (academic, arts, STEM), arts, community service, and employment. These activities are designed to foster personal growth, skill development (such as teamwork, leadership, or time management), and exploration of interests beyond core subjects, often complementing classroom learning. Mentoring provides structured relationships where individuals guide and support the personal growth of others. These services facilitate skill transfer, career development, and the building of confidence by fostering supportive, trusted relationships through which mentors share knowledge and insights to help mentees reach their full potential. Screening is a formal process of using specific tools and procedures to assess the treatment or support services needs of individuals. Treatment and support services delivery refers to the provision of a comprehensive, coordinated array of professional interventions and assistance designed to address an individual's specific physical, emotional, and behavioral health needs in a collaborative and person-centered manner. These services aim to restore functioning, promote recovery, and enable individuals to participate fully in their schools and communities. Referrals to treatment and support services are formal recommendations from one professional (such as a case manager) to another specialist or agency for additional care, including therapy, counseling, specialized treatment, or support groups. Referrals are used when a youth needs more than their initial provider can offer, ensuring a smoother transition to the right provider for specialized issues such as substance use, mental health, or specific medical conditions. This process helps youth connect with the precise resources needed, often involving coordination for effective follow-through. Trauma-informed support services are a strengths-based approach to care that recognize the widespread impact of trauma, focusing on safety, empowerment, and healing. Key principles include safety and trustworthiness, ensuring services create a supportive environment for survivors to regain control and feel safe. Parent and caregiver skills and family relationship programs teach positive parenting, communication, and bonding techniques to strengthen family ties, improve child and youth development, and prevent issues like substance abuse or neglect, using approaches such as home visits, group workshops, or practicing skills for managing emotions, setting boundaries, and nurturing secure attachments. Community-level programs and coalitions create healthier communities by bringing diverse local groups (such as schools, businesses, healthcare providers, or residents) together to tackle specific health issues, using shared resources for education, policy changes, and environmental improvements leading to lasting, collaborative solutions.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Which of the following best describes the program’s location(s)? Select all that apply.

What is the target population for the program? Select all that apply.

  • Code: Q3
  • Requirement: required
  • Definition: Answer options: o High school age students o Middle or junior high school age students o Elementary age students o Parents and caregivers o Service providers o Community members o Other, specify: ____ Target population is the group(s) of people for whom the program is primarily designed and who the program envisions will engage in the program’s services.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

What is the lowest age of youth who will be served by the program? (in years)

What is the highest age of youth who will be served by the program? (in years)

How many unique youth does the program expect to serve over the life of the award?

  • Code: Q6
  • Requirement: required
  • Definition: Unique means unduplicated. Individuals should only be counted once during a reporting period, regardless of the number of programs they may have been involved in. Youth refer to children and adolescents under the age of 18. Life of the award refers to the period from the start of the award to the closure of the award. For OJJDP awards, this is typically 3 years.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

What is the minimum length of participation for each youth?

What is the frequency of participation expected for each youth?

What tool or approach will be used to assess outcomes for youth?

  • Code: Q9
  • Requirement: required
  • Definition: Youth refer to children and adolescents under the age of 18. Outcomes refer to the specific, measurable benefits or changes in program participants that occur during or after their involvement in the program's activities. Examples include reduced substance use, increased stability, improved mental health, and increased prosocial behaviors.
  • Target rule: No target rule stated
  • Source: DOJ Office of Justice Programs, solicitation performance measures, https://ojjdp.ojp.gov/funding/performance-measures/pmqd/performance-measures-community-schools-youth-drug-prevention.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA Sober Truth on Prevention Underage Drinking Act Grants (STOP Act)

Estimated total number of individuals to be reached through indirect/population-based prevention efforts: ____ [If no strategy identified in I.B.5= “Direct/individual-based,” then skip I.C.2 and I.C.3] Estimated total number of individuals to be served. Enter the aggregate total number of individuals your grant program is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year.

Estimated total number of individuals to be served through direct/individual- based prevention efforts: Estimated total number of individuals to be served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year. If your grant program’s focal population does not include a specific demographic category, enter “0” for that category.

Estimated total number of individuals to be served through direct/individual- based prevention efforts by demographic category.

  • Code: ATR-3
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older:
  • Instrument: CORT
  • Reporting frequency: annual
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-cort-stop-act.pdf

Unduplicated total number of individuals reached through indirect/population- based prevention efforts:

  • Code: QPR-1
  • Requirement: required
  • Definition: a. Actual count: ____ b. Estimated count: ____ Unduplicated number of new individuals reached. Enter the aggregate number of new individuals your grant program reached through one or more indirect/population-based prevention efforts during the reporting period. If no new individuals were reached during the reporting period, enter “0.” In addition, indicate the number of new individuals reported as an actual count and/or as an estimated count. If either type of count is not applicable, enter “0” for that type. Note: The combined number of actual and estimated counts should equal the unduplicated number of new individuals reached. Regardless of the number of indirect/population-based strategies implemented or the number of times an individual may have been exposed to one, new individuals reached should only be counted once for the reporting period.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 9, https://www.samhsa.gov/sites/default/files/gpra-cort-stop-act.pdf

Unduplicated number of new individuals reached through indirect/population- based prevention efforts:

  • Code: QPR-2
  • Requirement: required
  • Definition: a. Actual count: ____ b. Estimated count: ____ [If no strategy identified in I.B.5 = “Direct/Individual-based,” then skip to Section D]. Unduplicated total number of individuals served. Enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals were served during the reporting period, enter “0.” Note: Regardless of the number of direct/individual-based prevention strategies implemented or the number of times an individual may have been exposed to one, individuals served should only be counted once for the reporting period.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 9, https://www.samhsa.gov/sites/default/files/gpra-cort-stop-act.pdf

Unduplicated total number of individuals served through direct/individual- based prevention efforts: ____ Unduplicated total number of individuals served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participants in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the total unduplicated number of individuals served reported in the previous item.

Unduplicated total number of individuals served through direct/individual- based prevention efforts by demographic category.

  • Code: QPR-4
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: (8) Unknown/not provided: c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older: (9) Unknown/not provided: Unduplicated number of new individuals served. Enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no new individuals were served during the reporting period, enter “0.” Note: Regardless of the number of direct/individual-based prevention strategies implemented or the number of times an individual may have been exposed to one, new individuals served should only be counted once.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-cort-stop-act.pdf

Number of new individuals served through direct/individual-based prevention efforts: ____ Unduplicated number of new individuals served by demographic category. For each demographic category, enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual prevention efforts during the reporting period. If no new individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participant in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the number of new individuals served reported in the previous item.

Number of new individuals served through direct/individual-based prevention efforts by demographic category.

  • Code: QPR-6
  • Requirement: required
  • Definition: a. Sex (1) Female: ____ (2) Male: ____ b. Race/Ethnicity (1) American Indian or Alaska Native: ____ (2) Asian: ____ (3) Black or African American: ____ (4) Hispanic or Latino: ____ (5) Middle Eastern or North African: ____ (6) Native Hawaiian or Pacific Islander: ____ (7) White: ____ (8) Unknown/not provided: ____ c. Age (1) 12 years and under: ____ (2) 13 to 17 years: ____ (3) 18 to 20 years: ____ (4) 21 to 24 years:____ (5) 25 to 44 years: ____ (6) 45 to 64 years: ____ (7) 65 to 74 years: ____ (8) 75 years and older:____ (9) Unknown/not provided: ____
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 11, https://www.samhsa.gov/sites/default/files/gpra-cort-stop-act.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA Strategic Prevention Framework for Prescription Drugs (SPF-Rx)

Estimated total number of individuals to be reached through indirect/population-based prevention efforts: [If no strategy identified in I.B.5= “Direct/Individual-based,” Then Skip I.C.2 and I.C.3] Estimated total number of individuals to be served. Enter the aggregate total number of individuals your grant program is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year.

Estimated total number of individuals to be served through direct/individual- based prevention efforts: Estimated total number of individuals to be served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year. If your grant program’s focal population does not include a specific demographic category, enter “0” for that category.

Estimated total number of individuals to be served through direct/individual- based prevention efforts by demographic category.

  • Code: ATR-3
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: SPF-Rx 3 c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older: SPF-Rx 4
  • Instrument: CORT
  • Reporting frequency: annual
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-cort-spf-rx.pdf

Unduplicated total number of individuals reached through indirect/population- based prevention efforts:

  • Code: QPR-1
  • Requirement: required
  • Definition: a. Actual count: ____ b. Estimated count: ____ Unduplicated number of new individuals reached. Enter the aggregate number of new individuals your grant program reached through one or more indirect/population-based prevention efforts during the reporting period. If no new individuals were reached during the reporting period, enter “0.” In addition, indicate the number of new individuals reported as an actual count and/or as an estimated count. If either type of count is not applicable, enter “0” for that type. Note: The combined number of actual and estimated counts should equal the unduplicated number of new individuals reached. Regardless of the number of indirect/population-based strategies implemented or the number of times an individual may have been exposed to one, new individuals reached should only be counted once for the reporting period.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-cort-spf-rx.pdf

Unduplicated number of new individuals reached through indirect/population- based prevention efforts:

  • Code: QPR-2
  • Requirement: required
  • Definition: a. Actual count: ____ b. Estimated count: ____ [If no strategy identified in I.B.5 = “Direct/individual-based,” then skip to Section D]. Unduplicated total number of individuals served. Enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals were served during the reporting period, enter “0.” Note: Regardless of the number of direct/individual-based prevention strategies implemented or the number of times an individual may have been exposed to one, individuals served should only be counted once for the reporting period.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-cort-spf-rx.pdf

Unduplicated total number of individuals served through direct/individual- based prevention efforts: Unduplicated total number of individuals served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participants in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the total unduplicated number of individuals served reported in the previous item. SPF-Rx 7

Unduplicated total number of individuals served through direct/individual- based prevention efforts by demographic category.

  • Code: QPR-4
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: (8) Unknown/not provided: c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older: (9) Unknown/not provided: SPF-Rx 8 Unduplicated number of new individuals served. Enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no new individuals were served during the reporting period, enter “0.” Note: Regardless of the number of direct/individual-based prevention strategies implemented or the number of times an individual may have been exposed to one, new individuals served should only be counted once.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 11, https://www.samhsa.gov/sites/default/files/gpra-cort-spf-rx.pdf

Number of new individuals served through direct/individual-based prevention efforts: ____ Unduplicated number of new individuals served by demographic category. For each demographic category, enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual prevention efforts during the reporting period. If no new individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participant in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the number of new individuals served reported in the previous item.

Number of new individuals served through direct/individual-based prevention efforts by demographic category.

  • Code: QPR-6
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: (8) Unknown/not provided: SPF-Rx 9 c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older: (9) Unknown/not provided:
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 12, https://www.samhsa.gov/sites/default/files/gpra-cort-spf-rx.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA Strategic Prevention Framework-Partnerships for Success (SPF-PFS)

Estimated total number of individuals to be reached through indirect/population-based prevention efforts: [If no strategy identified in I.B.5= “Direct/individual-based,” then skip I.C.2 and I.C.3] Estimated total number of individuals to be served. Enter the aggregate total number of individuals your grant program is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year.

Estimated total number of individuals to be served through direct/individual- based prevention efforts: Estimated total number of individuals to be served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year. If your grant program’s focal population does not include a specific demographic category, enter “0” for that category.

Estimated total number of individuals to be served through direct/individual- based prevention efforts by demographic category.

  • Code: ATR-3
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older:
  • Instrument: CORT
  • Reporting frequency: annual
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-cort-pfs.pdf

Unduplicated total number of individuals reached through indirect/population- based prevention efforts:

  • Code: QPR-1
  • Requirement: required
  • Definition: a. Actual count: ____ b. Estimated count: ____ Unduplicated number of new individuals reached. Enter the aggregate number of new individuals your grant program reached through one or more indirect/population-based prevention efforts during the reporting period. If no new individuals were reached during the reporting period, enter “0.” In addition, indicate the number of new individuals reported as an actual count and/or as an estimated count. If either type of count is not applicable, enter “0” for that type. Note: The combined number of actual and estimated counts should equal the unduplicated number of new individuals reached. Regardless of the number of indirect/population-based strategies implemented or the number of times an individual may have been exposed to one, new individuals reached should only be counted once for the reporting period.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-cort-pfs.pdf

Unduplicated number of new individuals reached through indirect/population- based prevention efforts:

  • Code: QPR-2
  • Requirement: required
  • Definition: a. Actual count: ____ b. Estimated count: ____ [If no strategy identified in I.B.5 = “Direct/individual-based,” then skip to Section D]. Unduplicated total number of individuals served. Enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals were served during the reporting period, enter “0.” Note: Regardless of the number of direct/individual-based prevention strategies implemented or the number of times an individual may have been exposed to one, individuals served should only be counted once for the reporting period.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-cort-pfs.pdf

Unduplicated total number of individuals served through direct/individual- based prevention efforts: Unduplicated total number of individuals served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participants in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the total unduplicated number of individuals served reported in the previous item.

Unduplicated total number of individuals served through direct/individual- based prevention efforts by demographic category.

  • Code: QPR-4
  • Requirement: required
  • Definition: a. Sex (1) Female: (2) Male: b. Race/Ethnicity (1) American Indian or Alaska Native: (2) Asian: (3) Black or African American: (4) Hispanic or Latino: (5) Middle Eastern or North African: (6) Native Hawaiian or Pacific Islander: (7) White: (8) Unknown/not provided: c. Age (1) 12 years and under: (2) 13 to 17 years: (3) 18 to 20 years: (4) 21 to 24 years: (5) 25 to 44 years: (6) 45 to 64 years: (7) 65 to 74 years: (8) 75 years and older: (9) Unknown/not provided: Unduplicated number of new individuals served. Enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no new individuals were served during the reporting period, enter “0.” Note: Regardless of the number of direct/individual-based prevention strategies implemented or the number of times an individual may have been exposed to one, new individuals served should only be counted once.
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 11, https://www.samhsa.gov/sites/default/files/gpra-cort-pfs.pdf

Number of new individuals served through direct/individual-based prevention efforts: ____ Unduplicated number of new individuals served by demographic category. For each demographic category, enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual prevention efforts during the reporting period. If no new individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participant in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the number of new individuals served reported in the previous item.

Number of new individuals served through direct/individual-based prevention efforts by demographic category.

  • Code: QPR-6
  • Requirement: required
  • Definition: a. Sex (1) Female: ____ (2) Male: ____ b. Race/Ethnicity (1) American Indian or Alaska Native: ____ (2) Asian: ____ (3) Black or African American: ____ (4) Hispanic or Latino: ____ (5) Middle Eastern or North African: ____ (6) Native Hawaiian or Pacific Islander: ____ (7) White: ____ (8) Unknown/not provided: ____ c. Age (1) 12 years and under: ____ (2) 13 to 17 years: ____ (3) 18 to 20 years: ____ (4) 21 to 24 years: ____ (5) 25 to 44 years: ____ (6) 45 to 64 years: ____ (7) 65 to 74 years: ____ (8) 75 years and older: ____ (9) Unknown/not provided: ____
  • Instrument: CORT
  • Reporting frequency: quarterly
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 12, https://www.samhsa.gov/sites/default/files/gpra-cort-pfs.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA discretionary grants: SUPRT-A Administrative Report

[AT BASELINE] What is the client’s month and year of birth (MM/YYYY)? | | | / | | | | |

What is the date of the assessment (MM/DD/YYYY)? | | | / | | | / | | | | | MONTH DAY YEAR

Which assessment type?

  • Code: A3
  • Requirement: required
  • Definition: Answer categories: Baseline | Reassessment (for clients in care at 3 or 6 months) | Annual (for clients in care for more than 12 months) | Record closeout
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[AT BASELINE ASSESSMENT ONLY] When did the client first receive services under this grant (MM/YYYY)? | | | / | | | | |

[AT REASSESSMENT OR ANNUAL OR CLOSEOUT] When did the client most recently receive services under this grant (MM/YYYY)? | | | / | | | | |

[AT RECORD CLOSEOUT] Why are you closing out this client’s record?

  • Code: A6
  • Requirement: required
  • Definition: Answer categories: Completed the program | No contact | Withdrew from/Refused treatment | Referred out | Transferred to a different grant program | Incarceration | Moved | Death | Other
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF QUESTION A6 IS DEATH] What is the cause of death?

What insurance does the client or guarantor have?

  • Code: B1
  • Requirement: required
  • Definition: Answer categories: SELECT ALL THAT APPLY | Medicare | Medicaid | Private Insurance or Employer Provided | TRICARE, CHAMPUS, CHAMPVA or other veteran or military health care | Indian Health Service Tribal Health Care | An assistance program [for example, a medication assistance program] | Any other type of health insurance or health coverage plan | None | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

In the past 30 days, was the client admitted to a hospital?

  • Code: B2
  • Requirement: required
  • Definition: Answer categories: Yes – Behavioral health reasons, for example mental health or substance use disorder | Yes – other health reasons, for example injury or illness | No | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

In the past 30 days, did the client visit an emergency department?

  • Code: B3
  • Requirement: required
  • Definition: Answer categories: Yes – Behavioral health reasons, for example mental health or substance use disorder | Yes – other health reasons, for example injury or illness | No | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

In the past 30 days, did the client experience a behavioral health crisis or request crisis response, for example from 988 or 911?

[IF QUESTION B4 IS YES] What is the primary crisis issue?

  • Code: B4a
  • Requirement: required
  • Definition: Answer categories: Suicide risk | Other risk of harm to self or others (e.g. NSSI, homicidal thoughts) | Mental health | Substance use other than overdose | Overdose | Other | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

In the past 30 days, did the client spend one or more nights at a residential behavioral health treatment facility, for example crisis stabilization or residential substance use disorder treatment facility, including for withdrawal management?

[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, was the client arrested, taken into custody, or detained?

  • Code: B6
  • Requirement: required
  • Definition: Answer categories: Yes | No | Not applicable | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, did the client spend one or more nights in jail or a correctional facility?

  • Code: B7
  • Requirement: required
  • Definition: Answer categories: Yes | No | Not applicable | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, has the client been on probation, parole, or intensive pretrial supervision for one or more days?

  • Code: B8
  • Requirement: required
  • Definition: Answer categories: Yes | No | Not applicable | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Within the past 30 days, was the client screened or assessed by your program for risk of suicidality?

  • Code: C1
  • Requirement: required
  • Definition: Answer categories: Yes – Screening result was negative (no or low risk) | Yes – Screening result was positive (at risk) | No, not screened or assessed | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Within the past 30 days, was the client screened or assessed by your program for substance use?

  • Code: C2
  • Requirement: required
  • Definition: Answer categories: Yes – Screening result was negative (no or low risk for substance use disorder (SUD)) | Yes – Screening result was positive (at risk for SUD) | No, not screened or assessed | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF QUESTION C2 IS “YES”] During the screening and assessment process, what was the reported use for the following substances? Recent use Past use (within the past (greater than Not Substance 30 days) 30 days) Never used documented a. Alcohol ...

  • Code: C3
  • Requirement: required
  • Definition: Item text continues:     b. Opioids ...     c. Cannabis ...     d. Sedative, hypnotic, or anxiolytics ...     e. Cocaine ...     f. Methamphetamine ...     g. Other stimulants ...     h. Hallucinogens or psychedelics ...     i. Inhalants ...     j. Other psychoactive substances ...     k. Tobacco or nicotine ...    
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Within the past 30 days, was the client screened or assessed by your program for the following disorders? (Please select one per disorder) Not Screened / documented in Disorder assessed Not screened Not applicable records a. Depression, depressive disorders ...     b.

  • Code: C4
  • Requirement: required
  • Definition: Item text continues: Anxiety disorders ...     c. Bipolar disorders ...     d. Psychosis, psychotic disorders ...     e. Trauma disorders, including PTSD ...     f. [IF CLIENT < 18 YEARS] Answer categories: Developmental, neurologic disorders ... | g. [IF CLIENT < 18 YEARS] | Behavioral and emotional...
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 8, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Substance use disorder diagnosis (record up to 3) Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis | | | | |

Mental health diagnosis (record up to 3) Enter ICD-10-CM/DSM-5 code F20-F99- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F20-F99- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F20-F99- or indicate no diagnosis | | | | |

Other factors influencing health status (record up to 3) Enter ICD-10-CM/DSM-5 code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | |

  • Code: D3
  • Requirement: required
  • Definition: Item text continues: | | Answer categories: No diagnosis | OTHER HEALTH STATUS QUESTIONS | Please indicate additional health status information as applicable and as documented in a clinical record.
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 9, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Is the client currently pregnant?

  • Code: D4
  • Requirement: required
  • Definition: Answer categories: Yes | No | Not applicable | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 9, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[CLINICAL HIGH RISK PSYCHOSIS CLIENTS ONLY] [AT REASSESSMENT OR ANNUAL] Has the client experienced an episode of psychosis since their last assessment?

[SUBSTANCE USE DISORDER TREATMENT CLIENTS ONLY] In the previous 30 days, did the client experience an overdose or take too much of a substance that resulted in needing supervision or medical attention?

  • Code: D6
  • Requirement: required
  • Definition: Answer categories: Yes | No | Not applicable | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF QUESTION D6 IS YES] After taking too much of a substance or overdosing, what intervention(s) did the client receive?

  • Code: D6a
  • Requirement: required
  • Definition: Answer categories: SELECT ALL THAT APPLY | Naloxone (Narcan) or other opioid overdose reversal medication | Care in an emergency department | Care from a primary care provider | Admission to a hospital | Supervision by someone else | Other | Not applicable | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[MAI PROGRAM CLIENTS ONLY] Has the client ever tested positive for HIV?

  • Code: D7
  • Requirement: required
  • Definition: Answer categories: Yes, HIV-positive | No, HIV-negative | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF QUESTION D7 IS YES, HIV-INFECTED] Is the client currently on ART?

  • Code: D7a
  • Requirement: required
  • Definition: Answer categories: Yes, currently taking ART | No, not currently taking ART | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF QUESTION D7 IS NO, HIV-NEGATIVE] Is the client currently taking HIV PrEP?

  • Code: D7b
  • Requirement: required
  • Definition: Answer categories: Yes, currently on PrEP | No, not currently on PrEP | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Has the client ever tested positive for Hepatitis C?

  • Code: D8
  • Requirement: required
  • Definition: Answer categories: Yes, active or previous Hepatitis C infection | No, never had Hepatitis C | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF QUESTION D8 IS YES, ACTIVE OR PREVIOUS HEPATITIS C INFECTION] Is the client currently taking viral Hepatitis C treatment?

  • Code: D8a
  • Requirement: required
  • Definition: Answer categories: Yes, currently taking viral Hepatitis C treatment | No, took treatment and cured | No, Hepatitis C infection naturally cleared without need for treatment | No, not currently taking treatment | Not documented in records or not documented in records using this standard
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 11, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Since the previous administrative assessment, did the project provide or refer the client for one or more behavioral health services?

If yes, please indicate which: Not No – not documented Yes – Referred for provided or in records / provided service referred unknown a. Case or care management or coordination ...     b. Person- or family-centered treatment planning ...     c.

  • Code: E1a
  • Requirement: required
  • Definition: Item text continues: Substance use psychoeducation ...     d. Mental health psychoeducation ...     e. Mental health therapy ...     f. Co-occurring therapy (substance use & mental health)     g. Group counseling ...     h. Individual counseling ...     i. Family counseling ...     j. Psychiatric rehabilitation services ...     k. Prescription medication for mental health disorder ...     l. Medication for substance use disorder...     m. Intensive day treatment ...     n. Withdrawal management (whether in hospital, Answer categories: residential, or ambulatory) ... | o. After care planning and referrals ...     | p. Co-occurring disorders (including developmental or | neurologic) ...
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 12, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

[IF E1a_l = MEDICATION FOR SUBSTANCE USE DISORDER IS YES – PROVIDED] Indicate medication received Not documented in No – not records / Yes – received received unknown a. Naltrexone ...    b.

  • Code: E2
  • Requirement: required
  • Definition: Item text continues: Extended-release Naltrexone ...    c. Disulfiram ...    d. Acamprosate ...    e. Methadone ...    f. Buprenorphine ...    g. Nicotine cessation therapy (e.g. Nicotine patch, gum, lozenge) ..    h. Bupropion ...    i. Varenicline ...    j. Other ...    CRISIS SERVICES
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 13, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Since the previous administrative assessment, did the project provide or refer the client for one or more crisis services?

If yes, please indicate which: Not No – not documented in Referred for provided or records / Yes – provided service referred unknown a. Crisis response planning ...     b. Crisis response ...     c.

  • Code: E3a
  • Requirement: required
  • Definition: Item text continues: Crisis stabilization ...     d. Crisis follow-up ...     RECOVERY AND SUPPORT SERVICES
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 13, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Since the previous administrative assessment, did the project provide or refer the client for one or more recovery support services?

If yes, please indicate which: No – not Not documented Referred for provided or in records / Yes – provided service referred unknown a. Employment support...     b. Family support services, including family peer

  • Code: E4a
  • Requirement: required
  • Definition: Answer categories: support ... | c. Childcare ...     | d. Transportation ...     | e. Education support...     | f. Housing support ...     | g. Recovery housing ...     | h. Spiritual, ceremonial, and/or traditional | activities ... | i. Mutual support groups ...     | j. Peer support specialist services, coaching or | mentoring ... | k. Respite care ...     | l. Therapeutic foster care ...     | INTEGRATED SERVICES
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 14, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

Since the previous administrative assessment, did the project provide or refer the client for one or more integrated services?

If yes, please indicate which: Not No – not documented in Referred for provided or records / Yes – provided service referred unknown a. Primary health care ...     b. Maternal health care or OB/GYN ...     c.

  • Code: E5a
  • Requirement: required
  • Definition: Item text continues: HIV testing ...     d. Viral hepatitis testing ...     e. HIV treatment ...     f. HIV pre-exposure prophylaxis (PrEP) ...     g. Viral hepatitis treatment ...     h. Other STI testing or treatment ...     i. Dental care ...    
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 15, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

What is the client’s race or ethnicity? Select all that apply and enter additional details in the spaces below.

  • Code: F1
  • Requirement: required
  • Definition: Answer categories: White – Provide details below. | German | Irish | English | Italian | Polish | French | Enter, for example, Scottish, Norwegian, Dutch, etc. ____ | Hispanic or Latino – Provide details below. | Mexican or Mexican American | Puerto Rican | Cuban | Salvadoran | Dominican | Colombian | Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____ | Black or African American – Provide details below. | African American | Jamaican | Haitian | Nigerian | Ethiopian | Somali | Enter, for example, Ghanaian, South African, Barbadian, etc. ____ | Asian – Provide details below. | Chinese | Filipino | Asian Indian | Vietnamese | Korean | Japanese | Enter, for example, Pakistani, Cambodian, Hmong, etc. ____ | American Indian or Alaska Native – Provide details below. | Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow | Inupiat Traditional Government, Tlingit, etc. ____ | Middle Eastern or North African – Provide details below. | Lebanese | Iranian | Egyptian | Syrian | Moroccan | Israeli | Enter, for example, Algerian, Iraqi, Kurdish, etc. ____ | Native Hawaiian or Pacific Islander – Provide details below. | Native Hawaiian | Samoan | Chamorro | Tongan | Fijian | Marshallese | Enter, for example, Palauan, Tahitian, Chuukese, etc. ____ | Race/ethnicity not captured in grantee records using detailed OMB categories. | Client/caregiver declined to provide race/ethnicity.
  • Instrument: SUPRT-A
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 16, https://www.samhsa.gov/sites/default/files/gpra-suprt-a-tool.pdf

What is the individual’s sex?

Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA discretionary grants: SUPRT-C client/caregiver form

Please choose the option that best applies to you right now:

  • Code: A1
  • Requirement: required
  • Definition: Answer categories: I consider myself to be in recovery from substance use issues | I consider myself to be in recovery from mental health issues | I consider myself to be in recovery from substance use and mental health issues | I do not consider myself to be in recovery for substance use or mental health issues | I prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: annual
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-annual-tool.pdf

As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below. Strongly Somewhat Somewhat Strongly Prefer not Agree Agree Agree Disagree Disagree Disagree to answer a.

  • Code: A2
  • Requirement: required
  • Definition: Item text continues: I am physically fine most days. ...        b. My mental health is fine most Answer categories: days. ... | c. My substance use does not | cause problems in my life. ... | d. I have stable housing. ...        | e. I have a steady job or am | involved in things like school,        | training, or volunteering. ... | f. My life has purpose and | meaning. ... | g. I have enough money to meet | my needs. ... | h. I am proud of the community I | live in and feel a part of it. ... | i. I am supported by the people | around me. ... | j. The future appears bright to me.        | k. I am in control of my life. ...        | l. I bounce back quickly after hard | times. ...
  • Instrument: SUPRT-C
  • Reporting frequency: annual
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-annual-tool.pdf

On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? | | | |

As a result of the services you received, which goals did you make progress on?

  • Code: A4
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | Improve the symptoms that led me to services (for example distress, anxiety) | Reduce my drug and/or alcohol use | Gain access to medical services I need | Enroll in or finish education (for example GED, degree, vocational training) | Get or maintain a job | Live in stable housing | Be a better parent or caregiver | Improve my friendships and relationships | Comply with court order or avoid contact with the police and/or justice system | Other goal - Please describe: ____ | Prefer not to answer | Thank you for completing this annual assessment form. | Public reporting burden for this collection of information is estimated to average 7 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / ANNUAL | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: annual
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-annual-tool.pdf

What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

  • Code: A1
  • Requirement: required
  • Definition: Answer categories: White – Provide details below. | German | Irish | English | Italian | Polish | French | Enter, for example, Scottish, Norwegian, Dutch, etc. ____ | Hispanic or Latino – Provide details below. | Mexican or Mexican American | Puerto Rican | Cuban | Salvadoran | Dominican | Colombian | Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____ | Black or African American – Provide details below. | African American | Jamaican | Haitian | Nigerian | Ethiopian | Somali | Enter, for example, Ghanaian, South African, Barbadian, etc. ____ | Asian – Provide details below. | Chinese | Filipino | Asian Indian | Vietnamese | Korean | Japanese | Enter, for example, Pakistani, Cambodian, Hmong, etc. ____ | American Indian or Alaska Native – Provide details below. | Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow | Inupiat Traditional Government, Tlingit, etc. ____ | Middle Eastern or North African – Provide details below. | Lebanese | Iranian | Egyptian | Syrian | Moroccan | Israeli | Enter, for example, Algerian, Iraqi, Kurdish, etc. ____ | Native Hawaiian or Pacific Islander – Provide details below. | Native Hawaiian | Samoan | Chamorro | Tongan | Fijian | Marshallese | Enter, for example, Palauan, Tahitian, Chuukese etc. ____
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

What is your sex?

Do you speak a language other than English at home? (If no, please skip to question A4.)

For persons speaking a language other than English (answering yes to the question above): What is this language(s)?

  • Code: A3a
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | American Sign Language (ASL) | Arabic | Chinese | French | Portuguese | Spanish | Other Language – specify: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

Have you ever served in the Armed Forces, the Reserves, the National Guard or other Uniformed Services?

Please respond to the following questions about your physical health. Prefer not Yes No to answer a. Are you deaf or do you have serious difficulty hearing? ...    b. Are you blind or do you have serious difficulty seeing, even when wearing

  • Code: A5
  • Requirement: required
  • Definition: Answer categories: glasses? ... | c. Because of a physical, mental, or emotional condition, do you have serious | difficulty concentrating, remembering, or making decisions? ... | d. Do you have serious difficulty walking or climbing stairs? ...    | e. Do you have difficulty dressing or bathing? ...    | f. Because of a physical, mental, or emotional condition, do you have | difficulty doing errands alone such as visiting a doctor’s office or shopping?
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

How hard is it for you to pay for the very basics like food, housing, medical care, and heating?

What is your living situation today?

  • Code: B2
  • Requirement: required
  • Definition: Answer categories: I have a steady place to live | I have a place to live today but I am worried about losing it in the future | I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living | outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

Which of the following best describes your current living situation?

  • Code: B3
  • Requirement: required
  • Definition: Answer categories: House or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

Are you currently employed?

  • Code: B4
  • Requirement: required
  • Definition: Answer categories: Employed, full time or part time (includes temporary, seasonal, hours change each week) | Not employed, seeking employment | Not employed, not seeking employment (includes if you are in school and not seeking a job, retired, | not looking for work because of a disability, a homemaker, etc.) | Other – specify: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

What is the highest level of education you have finished?

  • Code: B5
  • Requirement: required
  • Definition: Answer categories: Less than high school diploma | High school degree or GED | Some vocational, technical, college, or university credit(s) | Associate's degree or technical/vocational certificate | 4-year degree or higher | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

  • Code: B7
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | Yes, it has kept me from medical appointments or from getting my medications | Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need | No | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

Please choose the option that best applies to you right now:

  • Code: C1
  • Requirement: required
  • Definition: Answer categories: I consider myself to be in recovery from substance use issues | I consider myself to be in recovery from mental health issues | I consider myself to be in recovery from substance use and mental health issues | I do not consider myself to be in recovery for substance use or mental health issues | I prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 8, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below. Strongly Somewhat Somewhat Strongly Prefer not Agree Agree Agree Disagree Disagree Disagree to answer a.

  • Code: C2
  • Requirement: required
  • Definition: Item text continues: I am physically fine most days. ...        b. My mental health is fine most Answer categories: days. ... | c. My substance use does not | cause problems in my life. ... | d. I have stable housing. ...        | e. I have a steady job or am | involved in things like school,        | training, or volunteering. ... | f. My life has purpose and | meaning. ... | g. I have enough money to meet | my needs. ... | h. I am proud of the community I | live in and feel a part of it. ... | i. I am supported by the people | around me. ... | j. The future appears bright to me.        | k. I am in control of my life. ...        | l. I bounce back quickly after hard | times. ...
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 8, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? | | | |

Which goals do you have for participating in this program?

  • Code: C4
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | Improve the symptoms that led me to services (for example distress, anxiety) | Reduce my drug and/or alcohol use | Gain access to medical services I need | Enroll in or finish education (for example GED, degree, vocational training) | Get or maintain a job | Live in stable housing | Be a better parent or caregiver | Improve my friendships and relationships | Comply with court order or avoid contact with the police and/or justice system | Other goal - please describe: ____ | Prefer not to answer | Thank you for completing this baseline form. | Public reporting burden for this collection of information is estimated to average 15 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / BASELINE | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 9, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-baseline-tool.pdf

How hard is it for you to pay for the very basics like food, housing, medical care, and heating?

What is your living situation today?

  • Code: A2
  • Requirement: required
  • Definition: Answer categories: I have a steady place to live | I have a place to live today but I am worried about losing it in the future | I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living | outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

Which of the following best describes your current living situation?

  • Code: A3
  • Requirement: required
  • Definition: Answer categories: House or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

Are you currently employed?

  • Code: A4
  • Requirement: required
  • Definition: Answer categories: Employed, full time or part time (includes temporary, seasonal, hours change each week) | Not employed, seeking employment | Not employed, not seeking employment (includes in school not seeking, retired, due to disability, | homemaker, etc.) | Other – specify: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

What is the highest level of education you have finished?

  • Code: A5
  • Requirement: required
  • Definition: Answer categories: Less than high school diploma | High school degree or GED | Some vocational, technical, college, or university credit(s) | Associate's degree or technical/vocational Certificate | 4-year degree or higher | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

  • Code: A7
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | Yes, it has kept me from medical appointments or from getting my medications. | Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need. | No | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

Please choose the option that best applies to you right now:

  • Code: B1
  • Requirement: required
  • Definition: Answer categories: I consider myself to be in recovery from substance use issues | I consider myself to be in recovery from mental health issues | I consider myself to be in recovery from substance use and mental health issues | I do not consider myself to be in recovery for substance use or mental health issues | I prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below. Strongly Somewhat Somewhat Strongly Prefer not Agree Agree Agree Disagree Disagree Disagree to answer a.

  • Code: B2
  • Requirement: required
  • Definition: Item text continues: I am physically fine most days. ...        b. My mental health is fine most Answer categories: days. ... | c. My substance use does not | cause problems in my life. ... | d. I have stable housing. ...        | e. I have a steady job or am | involved in things like school,        | training, or volunteering. ... | f. My life has purpose and | meaning. ... | g. I have enough money to meet | my needs. ... | h. I am proud of the community I | live in and feel a part of it. ... | i. I am supported by the people | around me. ... | j. The future appears bright to me.        | k. I am in control of my life. ...        | l. I bounce back quickly after hard | times. ...
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? | | | |

As a result of the services you received, which goals did you make progress on?

  • Code: B4
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | Improve the symptoms that led me to services (for example distress, anxiety) | Reduce my drug and/or alcohol use | Gain access to medical services I need | Enroll in or finish education (for example GED, degree, vocational training) | Get or maintain a job | Live in stable housing | Be a better parent or caregiver | Improve my friendships and relationships | Comply with court order or avoid contact with the police and/or justice system | Other goal - Please describe: ____ | Prefer not to answer | Thank you for completing this reassessment form. | Public reporting burden for this collection of information is estimated to average 10 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / REASSESSMENT | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-adult-reassessment-tool.pdf

What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

  • Code: A1
  • Requirement: required
  • Definition: Answer categories: White – Provide details below. | German | Irish | English | Italian | Polish | French | Enter, for example, Scottish, Norwegian, Dutch, etc. ____ | Hispanic or Latino – Provide details below. | Mexican or Mexican American | Puerto Rican | Cuban | Salvadoran | Dominican | Colombian | Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____ | Black or African American – Provide details below. | African American | Jamaican | Haitian | Nigerian | Ethiopian | Somali | Enter, for example, Ghanaian, South African, Barbadian, etc. ____ | Asian – Provide details below. | Chinese | Filipino | Asian Indian | Vietnamese | Korean | Japanese | Enter, for example, Pakistani, Cambodian, Hmong, etc. ____ | American Indian or Alaska Native – Provide details below. | Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow | Inupiat Traditional Government, Tlingit, etc. ____ | Middle Eastern or North African – Provide details below. | Lebanese | Iranian | Egyptian | Syrian | Moroccan | Israeli | Enter, for example, Algerian, Iraqi, Kurdish, etc. ____ | Native Hawaiian or Pacific Islander – Provide details below. | Native Hawaiian | Samoan | Chamorro | Tongan | Fijian | Marshallese | Enter, for example, Palauan, Tahitian, Chuukese etc. ____
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-baseline-tool.pdf

What is your child’s sex?

Does your child speak a language other than English at home? (If no, please skip to question A4.)

For persons speaking a language other than English (answering yes to the question above): What is this language(s)?

Please respond to the following questions about your child’s physical health. Prefer not Yes No to answer a. Is your child deaf or does your child have serious difficulty hearing? ...    b. Is your child blind or does your child have serious difficulty seeing, even

  • Code: A4
  • Requirement: required
  • Definition: Answer categories: when wearing glasses? ... | c. Because of a physical, mental, or emotional condition, does your child | have serious difficulty concentrating, remembering, or making decisions? | d. Does your child have serious difficulty walking or climbing stairs? ...    | e. Does your child have difficulty dressing or bathing? ...    | f. Because of a physical, mental, or emotional condition, does your child | have difficulty doing errands alone such as visiting a doctor’s office or    | shopping? ...
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-baseline-tool.pdf

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

What is your child’s living situation today?

  • Code: B2
  • Requirement: required
  • Definition: Answer categories: My child has a steady place to live | My child has a place to live today but I am worried they may lose it in the future | My child does not have a steady place to live (My child is temporarily staying with others, in a hotel, in | a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or | in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-baseline-tool.pdf

Which of the following best describes your child’s current living situation?

  • Code: B3
  • Requirement: required
  • Definition: Answer categories: Your house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-baseline-tool.pdf

What is the highest level of education your child has finished?

In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?

  • Code: B5
  • Requirement: required
  • Definition: Answer categories: Enrolled, attending regularly | Enrolled, not attending regularly | Not enrolled | Prefer not to answer | Thank you for completing this baseline form. | Public reporting burden for this collection of information is estimated to average 10 minutes per response at | baseline. Send comments regarding this burden estimate, or any other aspect of this collection of information, to | the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room | 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not | required to respond to, a collection of information unless it displays a currently valid Office of Management and | Budget (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – CHILD / CAREGIVER / BASELINE | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-baseline-tool.pdf

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

What is your child’s living situation today?

  • Code: A2
  • Requirement: required
  • Definition: Answer categories: My child has a steady place to live | My child has a place to live today but I am worried they may lose it in the future | My child does not have a steady place to live (My child is temporarily staying with others, in a hotel, in | a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or | in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-reassessment-tool.pdf

Which of the following best describes your child’s current living situation?

  • Code: A3
  • Requirement: required
  • Definition: Answer categories: Your house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-reassessment-tool.pdf

What is the highest level of education your child has finished?

In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?

  • Code: A5
  • Requirement: required
  • Definition: Answer categories: Enrolled, attending regularly | Enrolled, not attending regularly | Not enrolled | Prefer not to answer | Thank you for completing this reassessment form. | Public reporting burden for this collection of information is estimated to average 5 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – CHILD / CAREGIVER / BASELINE | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-child-caregiver-reassessment-tool.pdf

What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

  • Code: A1
  • Requirement: required
  • Definition: Answer categories: White – Provide details below. | German | Irish | English | Italian | Polish | French | Enter, for example, Scottish, Norwegian, Dutch, etc. ____ | Hispanic or Latino – Provide details below. | Mexican or Mexican American | Puerto Rican | Cuban | Salvadoran | Dominican | Colombian | Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____ | Black or African American – Provide details below. | African American | Jamaican | Haitian | Nigerian | Ethiopian | Somali | Enter, for example, Ghanaian, South African, Barbadian, etc. ____ | Asian – Provide details below. | Chinese | Filipino | Asian Indian | Vietnamese | Korean | Japanese | Enter, for example, Pakistani, Cambodian, Hmong, etc. ____ | American Indian or Alaska Native | Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow | Inupiat Traditional Government, Tlingit, etc. ____ | Middle Eastern or North African – Provide details below. | Lebanese | Iranian | Egyptian | Syrian | Moroccan | Israeli | Enter, for example, Algerian, Iraqi, Kurdish, etc. ____ | Native Hawaiian or Pacific Islander – Provide details below. | Native Hawaiian | Samoan | Chamorro | Tongan | Fijian | Marshallese | Enter, for example, Palauan, Tahitian, Chuukese etc. ____
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-young-child-caregiver-baseline-tool.pdf

What is your child’s sex?

Please respond to the following questions about your child’s physical health. Prefer not Yes No to answer a. Is your child deaf or does your child have serious difficulty hearing? ...    b. Is your child blind or does your child have serious difficulty seeing, even

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

What is your child’s living situation today?

  • Code: B2
  • Requirement: required
  • Definition: Answer categories: My child has a steady place to live | My child has a place to live today but I am worried they may lose it in the future | My child does not have a steady place to live (My child is temporarily staying with others, in a hotel, in | a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or | in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-young-child-caregiver-baseline-tool.pdf

Which of the following best describes your child’s current living situation?

  • Code: B3
  • Requirement: required
  • Definition: Answer categories: Your house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer | Thank you for completing this baseline form. | Public reporting burden for this collection of information is estimated to average 6 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – YOUNG CHILD / CAREGIVER / | BASELINE | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-young-child-caregiver-baseline-tool.pdf

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

What is your child’s living situation today?

  • Code: A2
  • Requirement: required
  • Definition: Answer categories: My child has a steady place to live | My child has a place to live today but I am worried they may lose it in the future | My child does not have a steady place to live (My child is temporarily staying with others, in a hotel, in | a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or | in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-young-child-caregiver-reassessment-tool.pdf

Which of the following best describes your child’s current living situation?

  • Code: A3
  • Requirement: required
  • Definition: Answer categories: Your house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer | Thank you for completing this reassessment form. | Public reporting burden for this collection of information is estimated to average 3 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – YOUNG CHILD / CAREGIVER / | REASSESSMENT | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-young-child-caregiver-reassessment-tool.pdf

What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

  • Code: A1
  • Requirement: required
  • Definition: Answer categories: White – Provide details below. | German | Irish | English | Italian | Polish | French | Enter, for example, Scottish, Norwegian, Dutch, etc. ____ | Hispanic or Latino – Provide details below. | Mexican or Mexican American | Puerto Rican | Cuban | Salvadoran | Dominican | Colombian | Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____ | Black or African American – Provide details below. | African American | Jamaican | Haitian | Nigerian | Ethiopian | Somali | Enter, for example, Ghanaian, South African, Barbadian, etc. ____ | Asian – Provide details below. | Chinese | Filipino | Asian Indian | Vietnamese | Korean | Japanese | Enter, for example, Pakistani, Cambodian, Hmong, etc. ____ | American Indian or Alaska Native – Provide details below. | Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow | Inupiat Traditional Government, Tlingit, etc. ____ | Middle Eastern or North African – Provide details below. | Lebanese | Iranian | Egyptian | Syrian | Moroccan | Israeli | Enter, for example, Algerian, Iraqi, Kurdish, etc. ____ | Native Hawaiian or Pacific Islander – Provide details below. | Native Hawaiian | Samoan | Chamorro | Tongan | Fijian | Marshallese | Enter, for example, Palauan, Tahitian, Chuukese etc. ____
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

What is your sex?

Do you speak a language other than English at home? (If no, please skip to question A4.)

For persons speaking a language other than English (answering yes to the question above): What is this language(s)?

  • Code: A3a
  • Requirement: required
  • Definition: Answer categories: CHECK ALL THAT APPLY | American Sign Language (ASL) | Arabic | Chinese | French | Portuguese | Spanish | Other Language – specify: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

Please respond to the following questions about your physical health. Prefer not to Yes No answer a. Are you deaf or do you have serious difficulty hearing? ...    b. Are you blind or do you have serious difficulty seeing, even when    wearing glasses?

  • Code: A4
  • Requirement: required
  • Definition: Item text continues: ... c. Because of a physical, mental, or emotional condition, do you have Answer categories: serious difficulty concentrating, remembering, or making decisions? | d. Do you have serious difficulty walking or climbing stairs? ...    | e. Do you have difficulty dressing or bathing? ...    | f. Because of a physical, mental, or emotional condition, do you have | difficulty doing errands alone such as visiting a doctor’s office or    | shopping? ...
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

What is your living situation today?

  • Code: B1
  • Requirement: required
  • Definition: Answer categories: I have a steady place to live | I have a place to live today but I am worried about losing it in the future | I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living | outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

Which of the following best describes your current living situation?

  • Code: B2
  • Requirement: required
  • Definition: Answer categories: My parent/guardian’s house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

What is the highest level of education you have finished?

  • Code: B3
  • Requirement: required
  • Definition: Answer categories: Preschool – Kindergarten | Grade 1 – Grade 5 | Grade 6 – Grade 8 | Grade 9 – 12 | High school degree or GED | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

  • Code: B4
  • Requirement: required
  • Definition: Answer categories: Enrolled, attending regularly | Enrolled, not attending regularly | Not enrolled | Prefer not to answer | Thank you for completing this baseline form. | Public reporting burden for this collection of information is estimated to average 10 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – YOUTH / CLIENT / BASELINE | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: baseline
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 6, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-baseline-tool.pdf

What is your living situation today?

  • Code: A1
  • Requirement: required
  • Definition: Answer categories: I have a steady place to live | I have a place to live today but I am worried about losing it in the future | I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living | outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-reassessment-tool.pdf

Which of the following best describes your current living situation?

  • Code: A2
  • Requirement: required
  • Definition: Answer categories: My parent/guardian's house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-reassessment-tool.pdf

What is the highest level of education you have finished?

  • Code: A3
  • Requirement: required
  • Definition: Answer categories: Preschool – Kindergarten | Grade 1 – Grade 5 | Grade 6 – Grade 8 | Grade 9 - 12 | High school degree or GED | Prefer not to answer
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-reassessment-tool.pdf

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

  • Code: A4
  • Requirement: required
  • Definition: Answer categories: Enrolled, attending regularly | Enrolled, not attending regularly | Not enrolled | Prefer not to answer | Thank you for completing this reassessment form. | Public reporting burden for this collection of information is estimated to average 5 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – YOUTH / CLIENT / REASSESSMENT | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
  • Instrument: SUPRT-C
  • Reporting frequency: reassessment
  • Target rule: No target rule stated
  • Source: SAMHSA SUPRT data collection tools, p. 3, https://www.samhsa.gov/sites/default/files/gpra-suprt-c-youth-reassessment-tool.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA), SAMHSA discretionary grants: SUPRT-P Project tool

Total Number of Individuals Served

  • Code: TS1
  • Requirement: required
  • Definition: For annual targets, enter the total number of individuals your grant plans to serve through one or more grant services during the federal fiscal year specified. For quarterly reporting, enter the total number of unduplicated new individuals served with one or more grant services during the quarter. Total of new individuals served
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Total Served by Sex

  • Code: TS2
  • Requirement: required
  • Definition: Enter the number of new individuals served by sex. Each individual may be reported only under one sex. a. Female b. Male
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Total Served by Age Group

  • Code: TS3
  • Requirement: required
  • Definition: Enter the number of new individuals served for each of the following age groups. Each individual may be reported only under one age group. a. 0-9 years b. 10-17 years c. 18-20 years d. 21-24 years e. 25-44 years f. 45-64 years g. 65+ years h. Age not available
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 4, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Total Served by Military Status

  • Code: TS4
  • Requirement: required
  • Definition: Enter the number of new individuals served by military status. Each individual may be reported only under one military status group. a. Veteran b. Active Duty c. Reserve Status d. Military status not available
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of mental health awareness and promotion messaging impressions

Number of substance use prevention messaging impressions

Number of 988 awareness messaging impressions Outreach (O) Outreach (O) indicators track one-on-one contact with individuals outside of the clinical

  • Code: AW3
  • Requirement: required
  • Definition: setting to encourage care seeking, improve access to care, linkages to care, and retention in care. Outreach Result For annual targets, enter the total number of connections your grant plans to contact through outreach during the federal fiscal year specified. For quarterly reporting, enter the total number of connections your grant contacted through outreach during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 5, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of connections made through program outreach

Number of connections made through program outreach in geographically isolated areas

Number of connections made through program outreach in under- resourced communities

Number of new individuals vaccinated for hepatitis A (HAV)

Number of new individuals vaccinated for hepatitis B (HBV)

Number of opioid overdose reversal medication (OORM) kits purchased

Number of opioid overdose reversal medication (OORM) kits distributed

Number of prevention devices distributed

Number of medication lock boxes distributed

Number of sharps containers distributed

Number of medication disposal kits distributed Prevention Activities

Number of safe sex kits including condoms distributed

Number of wound management kits distributed

Number of gun locks distributed

Number of drug checking technologies distributed Prevention Education - Encounters (PE) indicators track components of universal prevention strategies delivered to individuals through one-on-one brief interactions or

  • Code: PA12
  • Requirement: required
  • Definition: group setting activities. Prevention Education - Encounters Result For annual targets, enter the total number of education encounters your grant plans to provide with prevention education, or promotion during the federal fiscal year specified. For quarterly reporting, enter the total number of education encounters your grant provided with prevention education or promotion during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of mental health promotion education encounters

Number of substance use education encounters

Number of substance use treatment education encounters

Number of substance use prevention education encounters

Number of substance use recovery education encounters

Number of prevention of suicide education encounters

Number of prevention of viral hepatitis, HIV, or other communicable diseases education encounters

Number of prevention of hepatitis B (HBV) education encounters

Number of prevention of hepatitis C (HBC) education encounters

Number of prevention of HIV education encounters

Number of pre-exposure prophylaxis for HIV (PrEP) education encounters

Number of post-exposure prophylaxis for HIV (PEP) education encounters

Number of prevention of bacterial sexually transmitted infections (STIs) education encounters Prevention Education - Individuals (PEI) indicators track components of universal

  • Code: PE13
  • Requirement: required
  • Definition: prevention strategies delivered to individuals through one-on-one brief interactions or group setting activities. Prevention Education - Encounters Result For annual targets, enter the total number of new individuals your grant plans to reach with prevention education, or promotion through outreach during the federal fiscal year specified. For quarterly reporting, enter the total number of new individuals your grant reached with prevention education or promotion during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 7, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of new individuals educated on mental health promotion

Number of new individuals educated on substance use

Number of new individuals educated on substance use treatment

Number of new individuals educated on substance use prevention

Number of new individuals educated on substance use recovery

Number of new individuals educated on prevention of suicide

Number of new individuals educated on prevention of viral hepatitis, HIV, or other communicable diseases

Number of new individuals educated on prevention of hepatitis B (HBV)

Number of new individuals educated on prevention of hepatitis C (HBC)

Number of new individuals educated on prevention of HIV

Number of new individuals educated on pre-exposure prophylaxis for HIV (PrEP)

Number of new individuals educated on post-exposure prophylaxis for HIV (PEP)

Number of new individuals educated on prevention of bacterial sexually transmitted infections (STIs)

Number of mental health screening encounters

Number of trauma experience screening encounters

Number of substance use screening encounters

Number of positive substance use screening encounters

Number of positive substance use screening encounters where services were declined

Number of suicide risk screening encounters

Number of positive suicide risk screening encounters

Number of screening encounters for risk factors associated with viral hepatitis, HIV, bacterial STIs, and tuberculosis

Number of screening encounters for risk of HIV

Number of screening encounters for risk of hepatitis B (HBV)

Number of screening encounters for risk of hepatitis C (HCV)

Number of screening encounters for risk of bacterial sexually transmitted infections (STIs)

Number of screening encounters for risk of tuberculosis (TB)

Number of supportive services needs screening encounters

Number of educational/vocational needs screening encounters

Number of employment needs screening encounters

Number of family support needs screening encounters

Number of childcare needs screening encounters Screening Encounter

Number of transportation needs screening encounters

Number of housing stability screening encounters

Number of screening encounters positive for experiencing homelessness

Number of recovery housing needs screening encounters

Number of peer support needs screening encounters

Number of food insecurity screening encounters

Number of other health conditions screening encounters Screening - Individual

  • Code: SE25
  • Requirement: required
  • Definition: For annual targets, enter the total number of individuals your grant plans to screen during the federal fiscal year specified. Do not enter targets for the number of individuals expected to have a positive screen. For quarterly reporting, enter the total number of individuals your grant screened during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 10, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of new individuals screened for mental health

Number of new individuals screened for substance use

Number of new individuals who screened positive for substance use

Number of new individuals who screened positive for substance use but declined services

Number of new individuals screened for suicide risk

Number of new individuals who screened positive for suicide risk

Number of new individuals screened for risk factors associated with viral hepatitis, HIV, bacterial STIs, and tuberculosis

Number of new individuals who screened at risk for HIV

Number of new individuals who screened at risk for hepatitis B (HBV)

Number of new individuals who screened at risk for hepatitis C (HCV)

Number of new individuals who screened at risk for bacterial sexually transmitted infections (STIs)

Number of new individuals who screened at risk for tuberculosis (TB) Screening - Individual

Number of new individuals screened for need for supportive services

Number of new individuals screened for educational/vocational needs

Number of new individuals screened for employment needs

Number of new individuals screened for family support needs

Number of new individuals screened for childcare needs

Number of new individuals screened for transportation needs

Number of new individuals screened for housing stability

Number of new individuals screened positive for homelessness

Number of new individuals screened for recovery housing needs

Number of new individuals screened for peer support needs

Number of new individuals screened for food insecurity

Number of new individuals screened for other health conditions Assessment and Testing

  • Code: SI24
  • Requirement: required
  • Definition: For annual targets, enter the total number of individuals your grant plans to test during the federal fiscal year specified. Do not enter targets for the number of individuals expected to have a positive test result or a diagnosis. For quarterly reporting, enter the total number of new individuals your grant assessed or tested during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 11, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of new individuals assessed for a serious mental illness (SMI) or a

Number of new individuals diagnosed with a SMI

Number of new individuals diagnosed with a SED

Number of new individuals assessed for a substance use disorder (SUD)

Number of new individuals diagnosed with an SUD

Number of new individuals tested for HIV

Number of new individuals who tested positive for HIV

Number of new individuals reached with a known HIV-positive status but not currently receiving treatment Assessment and Testing

Number of new individuals tested for hepatitis B (HBV)

Number of new individuals who tested positive for HBV

Number of new individuals reached with a known HBV-positive status but not currently receiving treatment

Number of new individuals tested for hepatitis C (HCV)

Number of new individuals who tested positive for HCV

Number of new individuals reached with a known HCV-positive status but not currently receiving treatment

Number of new individuals tested for bacterial sexually transmitted infections (STIs)

Number of new individuals who tested positive for gonorrhea

Number of new individuals who tested positive for chlamydia

Number of new individuals who tested positive for syphilis

Number of new individuals who tested for tuberculosis (TB)

Number of new individuals who tested positive for tuberculosis (TB) Referral (R) Referral indicators track efforts to refer the individuals identified with behavioral health

  • Code: AT20
  • Requirement: required
  • Definition: and related health or support needs. Referral Result For annual targets, enter the total number of referrals your grant plans to provide during the federal fiscal year specified. For quarterly reporting, enter the total number of referrals your grant provided during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 12, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of referrals provided to mental health services

Number of referrals provided to substance use services

Number of referrals provided to treatment after a positive screening for substance use

Number of referrals provided to treatment after an overdose reversal

Number of referrals provided to crisis services

Number of referrals provided to co-occurring treatment services Referral - Encounter

  • Code: R6
  • Requirement: required
  • Definition: For annual targets, enter the total number of referral encounters your grant plans to provide during the federal fiscal year specified. For quarterly reporting, enter the total number of referral encounters your grant provided during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 13, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of mental health service referral encounters

Number of traumatic stress referral encounters

Number of suicide prevention referral encounters

Number of substance use service referral encounters

Number of substance use service referral encounters after a positive screening for substance use

Number of substance use service referral encounters after an overdose reversal

Number of crisis service referral encounters

Number of co-occurring treatment service referral encounters Referral - Individual

  • Code: RE8
  • Requirement: required
  • Definition: For annual targets, enter the total number of new individuals your grant plans to refer during the federal fiscal year specified. For quarterly reporting, enter the total number of new individuals your grant referred during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 13, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of new individuals referred to mental health services

Number of new individuals referred to substance use services

Number of new individuals referred to treatment after a positive screening for substance use

Number of new individuals referred to treatment after an overdose reversal

Number of new individuals referred to crisis services

Number of new individuals referred to co-occurring treatment services

Number of new individuals linked to mental health services

Number of new individuals linked to substance use services

Number of new individuals linked to substance use treatment after an overdose reversal

Number of new individuals linked to care for viral hepatitis, HIV, or other communicable disease

Number of new individuals linked to HIV pre-exposure prophylaxis (PrEP)

Number of new individuals linked to HIV post-exposure prophylaxis (PEP)

Number of new individuals linked to HIV treatment

Number of new individuals linked to hepatitis B (HBV) treatment

Number of new individuals linked to hepatitis C (HCV) treatment Access and Linkage to Care or Treatment

  • Code: AC9
  • Requirement: required
  • Definition: AC 10. Number of new individuals linked to gonorrhea treatment
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 14, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of new individuals linked to chlamydia treatment

Number of new individuals linked to syphilis treatment

Number of new individuals linked to tuberculosis (TB) treatment

Number of new individuals linked to recovery and resilience support AC 15. Number of new individuals linked to educational or vocational support services

Number of new individuals linked to employment support services

Number of new individuals linked to family support services

Number of new individuals linked to childcare services

Number of new individuals linked to transportation services AC 20. Number of new individuals linked to housing support services

Number of new individuals linked to recovery housing services

Number of new individuals linked to peer coaching and mentoring

Number of new individuals linked to specialized population services

Number of new individuals linked to peer group/mutual support groups AC 25. Number of new individuals linked to respite care

Number of new individuals linked to therapeutic foster care

Number of new individuals linked to individualized advocacy or consultation

Number of new individuals linked to family unification services

Number of new individuals linked to other recovery support services AC 30. Number of new individuals linked to services for other health conditions

Number of brief intervention encounters for mental health

Number of brief intervention encounters for substance use

Number of brief treatment encounters for substance use

Number of brief intervention encounters for suicide prevention

Number of opioid overdose reversal medication (OORM) administration events Services

  • Code: BI5
  • Requirement: required
  • Definition: For annual targets, enter the total number of individuals your grant plans to serve during the federal fiscal year specified. For quarterly reporting, enter the total number of new individuals your grant served during the quarter.
  • Instrument: SUPRT-P
  • Reporting frequency: annual targets; quarterly results
  • Target rule: Applicant proposes the target
  • Source: SAMHSA SUPRT data collection tools, p. 16, https://www.samhsa.gov/sites/default/files/spars-suprt-p-tool.pdf

Number of new individuals who received mental health services

Number of new individuals who received therapy or counseling

Number of new individuals who received group counseling

Number of new individuals who received family counseling

Number of new individuals who received psychiatric rehabilitation services

Number of new individuals who received intensive day treatment

Number of new individuals who received substance use treatment services

Number of new individuals who received inpatient hospitalization treatment

Number of new individuals who received residential/rehabilitation

Number of new individuals who received outpatient treatment

Number of new individuals who received withdrawal management Services

Number of new individuals who received after care

Number of new individuals who received medications for substance use

Number of new individuals who received medications for opioid use disorder (MOUD) by mobile medication units

Number of new individuals who received medications for alcohol use disorder (MAUD) by mobile medication units

Number of new individuals who received suicide-specific services

Number of new individuals who received viral hepatitis, HIV, or other communicable disease services

Number of new individuals who received HIV PrEP

Number of new individuals who received HIV PEP

Number of new individuals who received treatment for HIV

Number of new individuals who received treatment for hepatitis B (HBV)

Number of new individuals who received direct acting antiviral-based treatment

Number of new individuals who received treatment for gonorrhea

Number of new individuals who received treatment for chlamydia

Number of new individuals who received treatment for syphilis

Number of new individuals who received treatment for tuberculosis (TB)

Number of new individuals who received support services that assist with recovery and resilience

Number of new individuals who received educational or vocational support services

Number of new individuals who received employment support services

Number of new individuals who received family support services

Number of new individuals who received childcare services

Number of new individuals who received transportation services

Number of new individuals who received housing support services Services

Number of new individuals who received recovery housing services

Number of new individuals who received peer coaching and mentoring

Number of new individuals who received specialized population services

Number of new individuals who participated in peer group/mutual support groups

Number of new individuals who received respite care

Number of new individuals who received therapeutic foster care

Number of new individuals who received individualized advocacy or consultation

Number of new individuals who received family unification services

Number of new individuals who received other recovery support services

Number of new individuals who received services for other health conditions

Number of new individuals who received primary health care services

Number of new individuals who received maternal health care services

Number of new individuals who received dental care services

Number of new individuals who received other health care services

Number of new individuals who received case management services

Number of new individuals who received care coordination

Number of new individuals who received treatment planning

Number of contacts who received mental health services

Number of contacts who received therapy or counseling

Number of contacts who received group counseling

Number of contacts who received family counseling

Number of contacts who received psychiatric rehabilitation services

Number of contacts who received intensive day treatment

Number of contacts who received behavioral health crisis services

Number of contacts who received mobile crisis response

Number of contacts who received crisis stabilization

Number of contacts who received crisis residential care

Number of contacts who received crisis follow-up care

Number of contacts who received crisis follow-up contacts (phone, chat, text, or other)

Number of contacts linked to behavioral health crisis services

Number of contacts linked to care for suicide risk

Number of contacts linked with 911/emergency services

Number of mental health intervention training participants

Number of mental health intervention training participants who were behavioral health professionals

Number of trauma informed care training participants

Number of trauma informed care training participants who were behavioral health professionals

Number of suicide prevention and/or behavioral health crisis response training participants

Number of suicide prevention and/or behavioral health crisis response training participants who were professional first responders

Number of suicide prevention and/or behavioral health crisis response training participants who were behavioral health professionals

Number of suicide prevention and/or behavioral health crisis response training participants who were medical health professionals

Number of substance use treatment training participants

Number of alcohol use disorder (AUD) training participants

Number of opioid use disorder (OUD) training participants

Number of opioid use disorder (OUD) training participants who were professional first responders

Number of opioid use disorder (OUD) training participants who were behavioral health professionals

Number of opioid use disorder (OUD) training participants who were medical health professionals

Number of opioid overdose response training participants Training and Workforce Development

Number of opioid overdose response training participants who were professional first responders

Number of opioid overdose response training participants who were other key community sector members

Number of opioid overdose response training participants who were school personnel trained

Number of opioid overdose response training participants who were behavioral health professionals

Number of opioid overdose response training participants who were non- traditional community sector members

Number of opioid overdose response training participants who were other community members

Number of opioid overdose response training participants who were family members of someone who experienced an opioid overdose

Number of opioid overdose response training participants who were individuals with lived experience

Number of opioid overdose reversal medication (OORM) administration training participants

Number of screening and identification of opioid use disorder (OUD) training participants

Number of medication administration for opioid use disorder (MOUD) training participants

Number of non-opioid therapies training participants

Number of peer support training participants who were individuals with lived experience

Number of co-occurring mental health and substance use disorder intervention training participants

Number of co-occurring mental health and substance use disorder intervention training participants who were professional first responders

Number of viral hepatitis, HIV, or other communicable diseases participants

Number of viral hepatitis, HIV, or other communicable diseases training participants who were behavioral health professionals

Number of opioid overdose reversals

Number of individuals who attempted suicide

Number of individuals who died by suicide

Number of families that successfully reunited with children in kinship or foster care arrangements through support services that assist with recovery

Number of new individuals who completed their course of treatment for hepatitis

Number of new individuals who achieved a hepatitis C (HCV) cure (SVR4 or later)

Number of new emergency department (ED) patients

Number of new ED patients treated for pain

Number of new ED patients treated with opioids for pain

Number of new ED patients who received non-opioid therapies for pain

Number of new emergency department (ED) patients who received an opioid prescription after receiving alternative therapies

Number of new emergency department (ED) patients presenting with pain

Number of ED patients with OUD to whom MOUD was provided in the ED

Number of new patients with OUD who were referred to outpatient MOUD services

[Q4 ONLY] Number of work group/advisory group/council members

[Q4 ONLY] Number of work group/advisory group/council members who have lived behavioral health experience

Number of new individuals with lived experience who provide behavioral health or recovery support services, including peer support or individual advocacy

Number of new individuals with lived experience who completed peer support certification

Number of new organizations that entered partnerships or collaboration with your grant

Number of new organizations that entered into formal written agreements Quarterly Narrative: Progress Report Overview

What you can collect, and how

Tier 1 is collected today from your own records. Tier 2 needs one free instrument. Tier 3 needs a partner under a data agreement. A measure that matches no rule has no tier.

Tier 1: Collect today from your own records

During this reporting period, how many unique youth received interventions to increase their knowledge of drug prevention?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

During this reporting period, how many unique youth received treatment, services, or support for exposure to violence or adverse experiences?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

During this reporting period, how many unique youth engaged in extracurricular activities, after- school programs, or mentoring programs?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

During this reporting period, how many unique parents or caregivers received interventions to increase their knowledge of drug prevention?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

During this reporting period, how many unique individuals engaged in community coalitions to reduce drug use?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

During this reporting period, how many unique law enforcement officers and personnel engaged in community coalitions to reduce drug use?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

During this reporting period, how many unique service providers were involved in screening youth to determine their needs or provide interventions to meet their needs?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Of the unique youth who received an intervention to increase drug prevention knowledge during this reporting period, how many perceived a high risk of harm associated with drug use?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Of the unique youth who received any intervention during this reporting period, how many perceived a high risk of harm associated with drug use?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Of the unique youth who received an intervention to increase drug prevention knowledge during this reporting period, how many expressed an intent to abstain from drugs?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Of the unique youth who received an intervention to increase drug prevention knowledge since the start of this award, how many self-reported substance use within the past 30 days?

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Estimated total number of individuals to be served through direct/individual- based prevention efforts by demographic category.

  • Collect today from your own records. An output the funder classes as a count of activity.

Unduplicated total number of individuals reached through indirect/population- based prevention efforts:

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated number of new individuals reached through indirect/population- based prevention efforts:

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated total number of individuals served through direct/individual- based prevention efforts: ____ Unduplicated total number of individuals served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participants in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the total unduplicated number of individuals served reported in the previous item.

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated total number of individuals served through direct/individual- based prevention efforts by demographic category.

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Number of new individuals served through direct/individual-based prevention efforts: ____ Unduplicated number of new individuals served by demographic category. For each demographic category, enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual prevention efforts during the reporting period. If no new individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participant in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the number of new individuals served reported in the previous item.

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals served through direct/individual-based prevention efforts by demographic category.

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Estimated total number of individuals to be served through direct/individual- based prevention efforts by demographic category.

  • Collect today from your own records. An output the funder classes as a count of activity.

Unduplicated total number of individuals reached through indirect/population- based prevention efforts:

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated number of new individuals reached through indirect/population- based prevention efforts:

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated total number of individuals served through direct/individual- based prevention efforts: Unduplicated total number of individuals served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participants in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the total unduplicated number of individuals served reported in the previous item. SPF-Rx 7

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated total number of individuals served through direct/individual- based prevention efforts by demographic category.

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Number of new individuals served through direct/individual-based prevention efforts: ____ Unduplicated number of new individuals served by demographic category. For each demographic category, enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual prevention efforts during the reporting period. If no new individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participant in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the number of new individuals served reported in the previous item.

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals served through direct/individual-based prevention efforts by demographic category.

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Estimated total number of individuals to be served through direct/individual- based prevention efforts by demographic category.

  • Collect today from your own records. An output the funder classes as a count of activity.

Unduplicated total number of individuals reached through indirect/population- based prevention efforts:

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated number of new individuals reached through indirect/population- based prevention efforts:

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated total number of individuals served through direct/individual- based prevention efforts: Unduplicated total number of individuals served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant program served through one or more direct/individual-based prevention efforts during the reporting period. If no individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participants in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the total unduplicated number of individuals served reported in the previous item.

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Unduplicated total number of individuals served through direct/individual- based prevention efforts by demographic category.

  • Collect today from your own records. A count of people served, held in the organization’s own records.

Number of new individuals served through direct/individual-based prevention efforts: ____ Unduplicated number of new individuals served by demographic category. For each demographic category, enter the aggregate unduplicated number of first-time participants your grant program served through one or more direct/individual prevention efforts during the reporting period. If no new individuals served identified with a specific demographic category, enter “0” for that category. Note: Program participants can identify as more than one race/ethnicity. In these cases, count the program participant in all the applicable categories. Although there may be overlap across demographic categories, no demographic category should exceed the number of new individuals served reported in the previous item.

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals served through direct/individual-based prevention efforts by demographic category.

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Total Number of Individuals Served

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Total Served by Sex

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Total Served by Age Group

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Total Served by Military Status

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Number of mental health awareness and promotion messaging impressions

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Number of substance use prevention messaging impressions

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Number of 988 awareness messaging impressions Outreach (O) Outreach (O) indicators track one-on-one contact with individuals outside of the clinical

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Number of connections made through program outreach

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Number of connections made through program outreach in geographically isolated areas

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Number of connections made through program outreach in under- resourced communities

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Number of new individuals vaccinated for hepatitis A (HAV)

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Number of new individuals vaccinated for hepatitis B (HBV)

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Number of opioid overdose reversal medication (OORM) kits purchased

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose reversal medication (OORM) kits distributed

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention devices distributed

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Number of medication lock boxes distributed

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of sharps containers distributed

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of medication disposal kits distributed Prevention Activities

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of safe sex kits including condoms distributed

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of wound management kits distributed

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Number of gun locks distributed

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of drug checking technologies distributed Prevention Education - Encounters (PE) indicators track components of universal prevention strategies delivered to individuals through one-on-one brief interactions or

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of mental health promotion education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use treatment education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use prevention education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use recovery education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention of suicide education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention of viral hepatitis, HIV, or other communicable diseases education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention of hepatitis B (HBV) education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention of hepatitis C (HBC) education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention of HIV education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of pre-exposure prophylaxis for HIV (PrEP) education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of post-exposure prophylaxis for HIV (PEP) education encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of prevention of bacterial sexually transmitted infections (STIs) education encounters Prevention Education - Individuals (PEI) indicators track components of universal

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on mental health promotion

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on substance use treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on substance use prevention

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on substance use recovery

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on prevention of suicide

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on prevention of viral hepatitis, HIV, or other communicable diseases

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on prevention of hepatitis B (HBV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on prevention of hepatitis C (HBC)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on prevention of HIV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on pre-exposure prophylaxis for HIV (PrEP)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on post-exposure prophylaxis for HIV (PEP)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals educated on prevention of bacterial sexually transmitted infections (STIs)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of mental health screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of trauma experience screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of positive substance use screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of positive substance use screening encounters where services were declined

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of suicide risk screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of positive suicide risk screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening encounters for risk factors associated with viral hepatitis, HIV, bacterial STIs, and tuberculosis

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening encounters for risk of HIV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening encounters for risk of hepatitis B (HBV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening encounters for risk of hepatitis C (HCV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening encounters for risk of bacterial sexually transmitted infections (STIs)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening encounters for risk of tuberculosis (TB)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of supportive services needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of educational/vocational needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of employment needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of family support needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of childcare needs screening encounters Screening Encounter

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Number of transportation needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of housing stability screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.
  • No cleared, validated, free outcome instrument exists for housing stability. The funder's own item (SAMHSA SUPRT-C client form, item A2d), an HMIS exit destination, or a partner record is the substitute.

Number of screening encounters positive for experiencing homelessness

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Number of recovery housing needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of peer support needs screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of food insecurity screening encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of other health conditions screening encounters Screening - Individual

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for mental health

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened positive for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened positive for substance use but declined services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for suicide risk

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened positive for suicide risk

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for risk factors associated with viral hepatitis, HIV, bacterial STIs, and tuberculosis

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened at risk for HIV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened at risk for hepatitis B (HBV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened at risk for hepatitis C (HCV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened at risk for bacterial sexually transmitted infections (STIs)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who screened at risk for tuberculosis (TB) Screening - Individual

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Number of new individuals screened for need for supportive services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for educational/vocational needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for employment needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for family support needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for childcare needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for transportation needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for housing stability

  • Collect today from your own records. A count of services or people, held in the organization’s own records.
  • No cleared, validated, free outcome instrument exists for housing stability. The funder's own item (SAMHSA SUPRT-C client form, item A2d), an HMIS exit destination, or a partner record is the substitute.

Number of new individuals screened positive for homelessness

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for recovery housing needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for peer support needs

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for food insecurity

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals screened for other health conditions Assessment and Testing

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals assessed for a serious mental illness (SMI) or a

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals diagnosed with a SMI

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Number of new individuals diagnosed with a SED

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Number of new individuals assessed for a substance use disorder (SUD)

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Number of new individuals diagnosed with an SUD

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Number of new individuals tested for HIV

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Number of new individuals who tested positive for HIV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals reached with a known HIV-positive status but not currently receiving treatment Assessment and Testing

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals tested for hepatitis B (HBV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested positive for HBV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals reached with a known HBV-positive status but not currently receiving treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals tested for hepatitis C (HCV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested positive for HCV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals reached with a known HCV-positive status but not currently receiving treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals tested for bacterial sexually transmitted infections (STIs)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested positive for gonorrhea

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested positive for chlamydia

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested positive for syphilis

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested for tuberculosis (TB)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who tested positive for tuberculosis (TB) Referral (R) Referral indicators track efforts to refer the individuals identified with behavioral health

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of referrals provided to mental health services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of referrals provided to substance use services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of referrals provided to treatment after a positive screening for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of referrals provided to treatment after an overdose reversal

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of referrals provided to crisis services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of referrals provided to co-occurring treatment services Referral - Encounter

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Number of mental health service referral encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of traumatic stress referral encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of suicide prevention referral encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use service referral encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use service referral encounters after a positive screening for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use service referral encounters after an overdose reversal

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of crisis service referral encounters

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of co-occurring treatment service referral encounters Referral - Individual

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals referred to mental health services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals referred to substance use services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals referred to treatment after a positive screening for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals referred to treatment after an overdose reversal

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals referred to crisis services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals referred to co-occurring treatment services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to mental health services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to substance use services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to substance use treatment after an overdose reversal

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to care for viral hepatitis, HIV, or other communicable disease

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to HIV pre-exposure prophylaxis (PrEP)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to HIV post-exposure prophylaxis (PEP)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to HIV treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to hepatitis B (HBV) treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to hepatitis C (HCV) treatment Access and Linkage to Care or Treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to chlamydia treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to syphilis treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to tuberculosis (TB) treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to recovery and resilience support AC 15. Number of new individuals linked to educational or vocational support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to employment support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to family support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to childcare services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to transportation services AC 20. Number of new individuals linked to housing support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to recovery housing services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to peer coaching and mentoring

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to specialized population services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to peer group/mutual support groups AC 25. Number of new individuals linked to respite care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to therapeutic foster care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to individualized advocacy or consultation

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to family unification services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals linked to other recovery support services AC 30. Number of new individuals linked to services for other health conditions

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of brief intervention encounters for mental health

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of brief intervention encounters for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of brief treatment encounters for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of brief intervention encounters for suicide prevention

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose reversal medication (OORM) administration events Services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received mental health services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received therapy or counseling

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received group counseling

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received family counseling

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received psychiatric rehabilitation services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received intensive day treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received substance use treatment services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received inpatient hospitalization treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received residential/rehabilitation

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Number of new individuals who received outpatient treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received withdrawal management Services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received after care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received medications for substance use

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received medications for opioid use disorder (MOUD) by mobile medication units

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received medications for alcohol use disorder (MAUD) by mobile medication units

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received suicide-specific services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received viral hepatitis, HIV, or other communicable disease services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received HIV PrEP

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received HIV PEP

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment for HIV

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment for hepatitis B (HBV)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received direct acting antiviral-based treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment for gonorrhea

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment for chlamydia

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment for syphilis

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment for tuberculosis (TB)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received support services that assist with recovery and resilience

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received educational or vocational support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received employment support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received family support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received childcare services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received transportation services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received housing support services Services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received recovery housing services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received peer coaching and mentoring

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received specialized population services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who participated in peer group/mutual support groups

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received respite care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received therapeutic foster care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received individualized advocacy or consultation

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received family unification services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received other recovery support services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received services for other health conditions

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received primary health care services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received maternal health care services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received dental care services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received other health care services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received case management services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received care coordination

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who received treatment planning

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received mental health services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received therapy or counseling

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received group counseling

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received family counseling

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received psychiatric rehabilitation services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received intensive day treatment

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received behavioral health crisis services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received mobile crisis response

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received crisis stabilization

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received crisis residential care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received crisis follow-up care

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts who received crisis follow-up contacts (phone, chat, text, or other)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts linked to behavioral health crisis services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts linked to care for suicide risk

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of contacts linked with 911/emergency services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of mental health intervention training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of mental health intervention training participants who were behavioral health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of trauma informed care training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of trauma informed care training participants who were behavioral health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of suicide prevention and/or behavioral health crisis response training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of suicide prevention and/or behavioral health crisis response training participants who were professional first responders

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of suicide prevention and/or behavioral health crisis response training participants who were behavioral health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of suicide prevention and/or behavioral health crisis response training participants who were medical health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of substance use treatment training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of alcohol use disorder (AUD) training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid use disorder (OUD) training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid use disorder (OUD) training participants who were professional first responders

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid use disorder (OUD) training participants who were behavioral health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid use disorder (OUD) training participants who were medical health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants Training and Workforce Development

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were professional first responders

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were other key community sector members

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were school personnel trained

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were behavioral health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were non- traditional community sector members

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were other community members

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were family members of someone who experienced an opioid overdose

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose response training participants who were individuals with lived experience

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose reversal medication (OORM) administration training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of screening and identification of opioid use disorder (OUD) training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of medication administration for opioid use disorder (MOUD) training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of non-opioid therapies training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of peer support training participants who were individuals with lived experience

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of co-occurring mental health and substance use disorder intervention training participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of co-occurring mental health and substance use disorder intervention training participants who were professional first responders

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of viral hepatitis, HIV, or other communicable diseases participants

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of viral hepatitis, HIV, or other communicable diseases training participants who were behavioral health professionals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of opioid overdose reversals

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of individuals who attempted suicide

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of individuals who died by suicide

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of families that successfully reunited with children in kinship or foster care arrangements through support services that assist with recovery

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who completed their course of treatment for hepatitis

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals who achieved a hepatitis C (HCV) cure (SVR4 or later)

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new ED patients treated for pain

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new ED patients treated with opioids for pain

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new ED patients who received non-opioid therapies for pain

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of ED patients with OUD to whom MOUD was provided in the ED

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new patients with OUD who were referred to outpatient MOUD services

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

[Q4 ONLY] Number of work group/advisory group/council members

  • Collect today from your own records. An output the funder classes as a count of activity.

[Q4 ONLY] Number of work group/advisory group/council members who have lived behavioral health experience

  • Collect today from your own records. An output the funder classes as a count of activity.

Number of new individuals with lived experience who provide behavioral health or recovery support services, including peer support or individual advocacy

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new individuals with lived experience who completed peer support certification

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new organizations that entered partnerships or collaboration with your grant

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Number of new organizations that entered into formal written agreements Quarterly Narrative: Progress Report Overview

  • Collect today from your own records. A count of services or people, held in the organization’s own records.

Tier 1 + 3: Collect today from your own records; and Needs a partner under an agreement

Number of new emergency department (ED) patients

Number of new emergency department (ED) patients who received an opioid prescription after receiving alternative therapies

Number of new emergency department (ED) patients presenting with pain

Tier 2: Add one free instrument

On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? | | | |

On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? | | | |

On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? | | | |

Implementation question, answered from program records

Did you adjust the program plan as described in your application’s proposal narrative? If yes, what adjustments did you make, and why?

Did you experience any challenges during this reporting period that impacted service delivery to program participants? If yes, how did you address the challenges, and do the challenges remain unresolved?

Did you engage with OJJDP training and technical assistance providers during this reporting period? If yes, did the providers adequately address your issue?

Did the program experience any challenges related to external factors beyond your control during the reporting period that impacted program outcomes? If yes, please describe the challenges.

Within the past 30 days, was the client screened or assessed by your program for risk of suicidality?

Within the past 30 days, was the client screened or assessed by your program for substance use?

Within the past 30 days, was the client screened or assessed by your program for the following disorders? (Please select one per disorder) Not Screened / documented in Disorder assessed Not screened Not applicable records a. Depression, depressive disorders ...     b.

Has the client ever tested positive for Hepatitis C?

Since the previous administrative assessment, did the project provide or refer the client for one or more behavioral health services?

Since the previous administrative assessment, did the project provide or refer the client for one or more crisis services?

Since the previous administrative assessment, did the project provide or refer the client for one or more recovery support services?

Since the previous administrative assessment, did the project provide or refer the client for one or more integrated services?

Do you speak a language other than English at home? (If no, please skip to question A4.)

Have you ever served in the Armed Forces, the Reserves, the National Guard or other Uniformed Services?

Are you currently employed?

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Are you currently employed?

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Does your child speak a language other than English at home? (If no, please skip to question A4.)

In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?

In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?

Do you speak a language other than English at home? (If no, please skip to question A4.)

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?

Narrative response

How would you describe progress made toward this award's goals and objectives during this reporting period?

What services are supported, in whole or in part, by OJJDP’s grant funds? Select all that apply.

Which of the following best describes the program’s location(s)? Select all that apply.

What is the target population for the program? Select all that apply.

What is the lowest age of youth who will be served by the program? (in years)

What is the highest age of youth who will be served by the program? (in years)

What is the minimum length of participation for each youth?

What is the frequency of participation expected for each youth?

What tool or approach will be used to assess outcomes for youth?

What is the date of the assessment (MM/DD/YYYY)? | | | / | | | / | | | | | MONTH DAY YEAR

Which assessment type?

What insurance does the client or guarantor have?

If yes, please indicate which: Not No – not documented Yes – Referred for provided or in records / provided service referred unknown a. Case or care management or coordination ...     b. Person- or family-centered treatment planning ...     c.

If yes, please indicate which: Not No – not documented in Referred for provided or records / Yes – provided service referred unknown a. Crisis response planning ...     b. Crisis response ...     c.

If yes, please indicate which: No – not Not documented Referred for provided or in records / Yes – provided service referred unknown a. Employment support...     b. Family support services, including family peer

If yes, please indicate which: Not No – not documented in Referred for provided or records / Yes – provided service referred unknown a. Primary health care ...     b. Maternal health care or OB/GYN ...     c.

What is the client’s race or ethnicity? Select all that apply and enter additional details in the spaces below.

What is the individual’s sex?

Please choose the option that best applies to you right now:

As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below. Strongly Somewhat Somewhat Strongly Prefer not Agree Agree Agree Disagree Disagree Disagree to answer a.

As a result of the services you received, which goals did you make progress on?

What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

What is your sex?

What is your living situation today?

Which of the following best describes your current living situation?

What is the highest level of education you have finished?

Please choose the option that best applies to you right now:

As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below. Strongly Somewhat Somewhat Strongly Prefer not Agree Agree Agree Disagree Disagree Disagree to answer a.

Which goals do you have for participating in this program?

What is your living situation today?

Which of the following best describes your current living situation?

What is the highest level of education you have finished?

Please choose the option that best applies to you right now:

As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below. Strongly Somewhat Somewhat Strongly Prefer not Agree Agree Agree Disagree Disagree Disagree to answer a.

As a result of the services you received, which goals did you make progress on?

What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

What is your child’s sex?

What is your child’s living situation today?

Which of the following best describes your child’s current living situation?

What is the highest level of education your child has finished?

What is your child’s living situation today?

Which of the following best describes your child’s current living situation?

What is the highest level of education your child has finished?

What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

What is your child’s sex?

What is your child’s living situation today?

Which of the following best describes your child’s current living situation?

What is your child’s living situation today?

Which of the following best describes your child’s current living situation?

What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.

What is your sex?

What is your living situation today?

Which of the following best describes your current living situation?

What is the highest level of education you have finished?

What is your living situation today?

Which of the following best describes your current living situation?

What is the highest level of education you have finished?

Planning figure, no collection needed

How many unique youth does the program expect to serve over the life of the award?

Estimated total number of individuals to be reached through indirect/population-based prevention efforts: ____ [If no strategy identified in I.B.5= “Direct/individual-based,” then skip I.C.2 and I.C.3] Estimated total number of individuals to be served. Enter the aggregate total number of individuals your grant program is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year.

Estimated total number of individuals to be served through direct/individual- based prevention efforts: Estimated total number of individuals to be served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year. If your grant program’s focal population does not include a specific demographic category, enter “0” for that category.

Estimated total number of individuals to be reached through indirect/population-based prevention efforts: [If no strategy identified in I.B.5= “Direct/Individual-based,” Then Skip I.C.2 and I.C.3] Estimated total number of individuals to be served. Enter the aggregate total number of individuals your grant program is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year.

Estimated total number of individuals to be served through direct/individual- based prevention efforts: Estimated total number of individuals to be served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year. If your grant program’s focal population does not include a specific demographic category, enter “0” for that category.

Estimated total number of individuals to be reached through indirect/population-based prevention efforts: [If no strategy identified in I.B.5= “Direct/individual-based,” then skip I.C.2 and I.C.3] Estimated total number of individuals to be served. Enter the aggregate total number of individuals your grant program is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year.

Estimated total number of individuals to be served through direct/individual- based prevention efforts: Estimated total number of individuals to be served by demographic category. For each demographic category, enter the aggregate total number of individuals your grant is planning to serve through one or more direct/individual-based prevention efforts during the federal fiscal year. If your grant program’s focal population does not include a specific demographic category, enter “0” for that category.

Tier not determined

Past 30-day use

Perception of risk

Perception of parental disapproval

Perception of peer disapproval

Annual progress report: community profile, sector and youth engagement, coalition capacity, risk and protective factors, and youth substance use prevention strategies

Short-term, intermediate and long-term outcome measures identified by the recipient from its program logic model

[AT BASELINE] What is the client’s month and year of birth (MM/YYYY)? | | | / | | | | |

[AT BASELINE ASSESSMENT ONLY] When did the client first receive services under this grant (MM/YYYY)? | | | / | | | | |

[AT REASSESSMENT OR ANNUAL OR CLOSEOUT] When did the client most recently receive services under this grant (MM/YYYY)? | | | / | | | | |

[AT RECORD CLOSEOUT] Why are you closing out this client’s record?

[IF QUESTION A6 IS DEATH] What is the cause of death?

In the past 30 days, was the client admitted to a hospital?

In the past 30 days, did the client visit an emergency department?

In the past 30 days, did the client experience a behavioral health crisis or request crisis response, for example from 988 or 911?

[IF QUESTION B4 IS YES] What is the primary crisis issue?

In the past 30 days, did the client spend one or more nights at a residential behavioral health treatment facility, for example crisis stabilization or residential substance use disorder treatment facility, including for withdrawal management?

[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, was the client arrested, taken into custody, or detained?

[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, did the client spend one or more nights in jail or a correctional facility?

[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, has the client been on probation, parole, or intensive pretrial supervision for one or more days?

[IF QUESTION C2 IS “YES”] During the screening and assessment process, what was the reported use for the following substances? Recent use Past use (within the past (greater than Not Substance 30 days) 30 days) Never used documented a. Alcohol ...

Substance use disorder diagnosis (record up to 3) Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis | | | | |

Mental health diagnosis (record up to 3) Enter ICD-10-CM/DSM-5 code F20-F99- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F20-F99- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code F20-F99- or indicate no diagnosis | | | | |

Other factors influencing health status (record up to 3) Enter ICD-10-CM/DSM-5 code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | | Enter ICD-10-CM/DSM-5 code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | |

Is the client currently pregnant?

[CLINICAL HIGH RISK PSYCHOSIS CLIENTS ONLY] [AT REASSESSMENT OR ANNUAL] Has the client experienced an episode of psychosis since their last assessment?

[SUBSTANCE USE DISORDER TREATMENT CLIENTS ONLY] In the previous 30 days, did the client experience an overdose or take too much of a substance that resulted in needing supervision or medical attention?

[IF QUESTION D6 IS YES] After taking too much of a substance or overdosing, what intervention(s) did the client receive?

[MAI PROGRAM CLIENTS ONLY] Has the client ever tested positive for HIV?

[IF QUESTION D7 IS YES, HIV-INFECTED] Is the client currently on ART?

[IF QUESTION D7 IS NO, HIV-NEGATIVE] Is the client currently taking HIV PrEP?

[IF QUESTION D8 IS YES, ACTIVE OR PREVIOUS HEPATITIS C INFECTION] Is the client currently taking viral Hepatitis C treatment?

[IF E1a_l = MEDICATION FOR SUBSTANCE USE DISORDER IS YES – PROVIDED] Indicate medication received Not documented in No – not records / Yes – received received unknown a. Naltrexone ...    b.

For persons speaking a language other than English (answering yes to the question above): What is this language(s)?

Please respond to the following questions about your physical health. Prefer not Yes No to answer a. Are you deaf or do you have serious difficulty hearing? ...    b. Are you blind or do you have serious difficulty seeing, even when wearing

How hard is it for you to pay for the very basics like food, housing, medical care, and heating?

How hard is it for you to pay for the very basics like food, housing, medical care, and heating?

For persons speaking a language other than English (answering yes to the question above): What is this language(s)?

Please respond to the following questions about your child’s physical health. Prefer not Yes No to answer a. Is your child deaf or does your child have serious difficulty hearing? ...    b. Is your child blind or does your child have serious difficulty seeing, even

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

Please respond to the following questions about your child’s physical health. Prefer not Yes No to answer a. Is your child deaf or does your child have serious difficulty hearing? ...    b. Is your child blind or does your child have serious difficulty seeing, even

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?

For persons speaking a language other than English (answering yes to the question above): What is this language(s)?

Please respond to the following questions about your physical health. Prefer not to Yes No answer a. Are you deaf or do you have serious difficulty hearing? ...    b. Are you blind or do you have serious difficulty seeing, even when    wearing glasses?

What grantees achieved

2 grantees of Middle School Initiatives – Substance Abuse Prevention reported 4 results against targets over 2 periods; the median result was 134% of target (middle half 125% to 143%), and 100% met or exceeded the target. Source: Children's Services Council of Broward County, annual performance reports, https://www.cscbroward.org/wp-content/uploads/2025/01/APR-FY-23-24-Book-002.pdf.

1 grantee of Middle School Initiatives - Substance Abuse Prevention - Leverage reported 2 results against targets over 1 period; the median result was 127% of target (middle half 126% to 128%), and 100% met or exceeded the target. Source: Children's Services Council of Broward County, annual performance reports, https://www.cscbroward.org/wp-content/uploads/2025/01/APR-FY-23-24-Book-002.pdf.

Program-level figures, not individual grantees: Substance Abuse Prevention reported 37 results against targets over 5 periods; the median result was 89% of target (middle half 82% to 100%), and 24% met or exceeded the target. Source: Illinois Comptroller Public Accountability Reports, https://par.illinoiscomptroller.gov/index.cfm?AgencyNo=601&FiscalYear=2022&ProgramAreaGroupID=3&ProgramID=1&UniqueProgramID=6011.

Program-level figures, not individual grantees: Safe and Drug Free Schools State Grants reported 14 results against targets over 3 periods; the median result was 100% of target (middle half 96% to 110%), and 57% met or exceeded the target. Source: OMB PART assessments (ExpectMore.gov archive), https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/omb/expectmore/detail/10002335.2004.html.

Program-level figures, not individual grantees: Substance Abuse Prevention and Treatment Block Grant reported 9 results against targets over 8 periods; the median result was 98% of target (middle half 97% to 106%), and 44% met or exceeded the target. Source: OMB PART assessments (ExpectMore.gov archive), https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/omb/expectmore/detail/10002335.2004.html.

Program-level figures, not individual grantees: Drug-Free Communities Support Program reported 8 results against targets over 2 periods; the median result was 102% of target (middle half 100% to 108%), and 88% met or exceeded the target. Source: OMB PART assessments (ExpectMore.gov archive), https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/omb/expectmore/detail/10002335.2004.html.

Program-level figures, not individual grantees: Youth Anti-Drug Media Campaign reported 3 results against targets over 3 periods; the median result was 100% of target (middle half 98% to 103%), and 67% met or exceeded the target. Source: OMB PART assessments (ExpectMore.gov archive), https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/omb/expectmore/detail/10002335.2004.html.

Substance Abuse Prevention Projects of Regional and National Significance: the source lists 12 rows for this program but none carries both a target and a result, so no attainment is computed. Source: OMB PART assessments (ExpectMore.gov archive), https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/omb/expectmore/detail/10002335.2004.html.

Target-setting language with precedent

Each item comes from one funder, one program or one department; none is a government-wide rule.

Showing clauses from HHS and Education.

What reviewers penalize

These ten weaknesses recur in 17 published reviewer critiques, mostly U.S. Department of Education and NIH. The count is the number of critiques that name it, not a rate, and a reviewer comment is a judgment.

Protocol skeleton

Draft text, edit before use

Measures: Past 30-day use; Perception of risk; Perception of parental disapproval; Perception of peer disapproval; Annual progress report: community profile, sector and youth engagement, coalition capacity, risk and protective factors, and youth substance use prevention strategies; Short-term, intermediate and long-term outcome measures identified by the recipient from its program logic model; During this reporting period, how many unique youth received interventions to increase their knowledge of drug prevention?; During this reporting period, how many unique youth received treatment, services, or support for exposure to violence or adverse experiences?; During this reporting period, how many unique youth engaged in extracurricular activities, after- school programs, or mentoring programs?; During this reporting period, how many unique parents or caregivers received interventions to increase their knowledge of drug prevention?; During this reporting period, how many unique individuals engaged in community coalitions to reduce drug use?; During this reporting period, how many unique law enforcement officers and personnel engaged in community coalitions to reduce drug use?; and 387 more listed above. Baseline: ____ months from award, using CDC-RFA-CE-26-0061 NOFO, Required performance measures; CORT; SUPRT-A; SUPRT-C; SUPRT-P. Targets: set from the observed baseline at month ____, or committed now as a change of ____ percentage points from baseline.

Missing-data plan (how dropout and missing observations will be handled): ____

Comparison group or baseline (what you compare against and how the groups started): ____

Fallback if recruitment, data access or the first analysis falls short: ____

Fidelity threshold (what counts as full implementation, and how it is measured): ____

Instrument named, with its validity evidence and its rights (license) status: ____

Numeric target for each measure (a number, not a direction): ____

Analysis for each outcome (method, comparison, adjustment): ____

Data protection and data management (who holds identifiable data, where, for how long): ____

Feedback schedule (who reviews the data, how often, and what changes as a result): ____

Evaluator role and independence (who evaluates and how they are separate from delivery): ____

The text is copied or summarized from public documents. It is not legal advice.