Form Tab C Tab C Final

OMB No. 0930-0080

OMB No. 0930-0080

Approval Expires: 08-31-2007

FINAL

UNIFORM APPLICATION

FY 20087

SUBSTANCE ABUSE PREVENTION AND TREATMENT

BLOCK GRANT

42 U.S.C. 300x-21 through 300x-6664

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Center for Substance Abuse Prevention

INTRODUCTION

The SAPT Block Grant application format provides the means for States to comply with the reporting provisions of the Public Health Service Act (42 USC 300x-21-664), as implemented by the Interim Final Rule (45 CFR Part 96, part XI). With regard to the requirements for Goal 8, the Annual Synar Report format provides the means for States to comply with the reporting provisions of the Synar Amendment (sSection 1926 of the Public Health Service Act), as implemented by the Tobacco Regulation for the SAPT Block Grant (45 CFR Part 96, part IV).

Public reporting burden for this collection of information is estimated to average 470 hours per respondent for sSections I-III, 40 hours per respondent for Section IV-A and 5642.75 hours per respondent for Section IV-B, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (OMB No. 0930-0080); 1 Choke Cherry Road, Room 7-1042, Rockville, Maryland 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 OMB control number. The OMB control number for this project is OMB No. 0930-0080.

Although States are free to submit their block grant application and annual report using the MS Word version, a web-based application has been developed to facilitate States’ completion, submission and revision of their block grant application. The Web Block Grant Application System WEGeb-BGAS can be accessed via the wWorld wWide wWeb at http://bgas.samhsa.gov .

How the application helps the Substance Abuse and Mental Health Services Administration

Part of the mission of the Center for Substance Abuse Treatment (CSAT) and the Center for Substance Abuse Prevention (CSAP) is to assist States¹ and communities to improve activities and services provided with funds from the Substance Abuse Prevention and Treatment (SAPT) Block Grant. One strategy CSAT and CSAP are using to promote increased State accountability for the management of block grant funds is the uniform application. In accordance with the block grant regulations, the States are asked to provide detailed data on expenditures of the FY 20054 SAPT Block Grant (and intended use of the FY 20087 SAPT Block Grant) and from State and local government funds. Another strategy is the State Systems Development Program and the Strategic Prevention Framework Advancement and Support project, which are enhanced technical assistance programs involving conferences and workshops, development of training materials and knowledge transfer manuals, and on-site consultation.

How the application can help States

The information gathered for the application can help States describe and analyze sub-State needs. This data can also be used to report to the State legislature and other State and local organizations. Aggregated statistical data from States’ applications can demonstrate to Congress the magnitude of the national substance abuse problem. This information will also provide Congress with a better understanding of funding needs.

Where and when to submit the application

Submit one signed original of the Assurance and Certifications by October 1, 20076 to:

Ms. LouEllen M. Rice, Grants Management Officer

Substance Abuse and Mental Health Services Administration

Office of Program Services

Division of Grants Management

Regular Mail Overnight mail:

1 Choke Cherry Road, Room 7-1091 (240) 276-1404

Rockville, Maryland 20857 1 Choke Cherry Road, Room 7-1091

Rockville, Maryland 20850

Overview of the application

The application has four sections. It covers the SAPT Block Grant for the prevention and treatment of substance abuse. AllSome sections require the completion of standard forms.

Section	Contents	Forms
Section I	Identifying information, Table of Contents, and Funding Agreements/Certifications	Forms 1, 2, 3
Section II	Annual Report – Actual use of FY 20054 SAPT Block Grant Funds. Narrative: FY 20054 Annual Report, FY 20076 Progress Report, FY 20087 Intended Use. Attachments – Special requirements and waivers	Forms 4, 6, 6aA, 7aA, 7bB, and Tables I through IV
Section III	State Plan – Intended use of FY 20087 SAPT Block Grant Funds	Forms 8, 9, 11, 12
Section IVva A	Voluntary Treatment Performance Measures	Forms T1-T7
Section IVb B	Voluntary Prevention Performance Measures	Forms P1-P154

There are detailed instructions for each section and each form. All States must use this format. The structure of the application cannot be changed. It must be organized according to the Table of Contents (Form 2) that serves as a checklist and helps you ensure that your application is complete.

Each page of the application should be numbered consecutively with numbers centered at the bottom of the page. The State’s name must be entered on every form. The application should be clipped or stapled securely, but not bound to hinder reproduction.

If you are using Web-BGAS, the State need only print out three Certifications/Assurances (Form 3), Assurances-Non-Construction Programs, and Certifications, sign and mail them early enough to arrive at SAMHSA by October 1, 20076. The Disclosure of Lobbying Activities form must also be signed, if applicable.

Copies of the uniform application and forms are available in MS Word from CSAT via the SAMHSA/CSAT home page. To download the application, go to:

http://www.tie.samhsa.gov/sapt2007.htmhttp://www.tie.samhsa.gov/sapt20087.htm.htm

Directions to download and decompress the files are available on the page.

Footnotes

Your State may wish to add footnotes to data forms to qualify or otherwise explain data entries. You may do so on any form in the application. If you are using the Web-BGAS you should click on the footnote button and enter the information you desire. If you are using the MS Word version you may use the footnote feature found under the “Insert” pull down menu on most MS Word versions.

What to do if your State cannot complete all items in Sections I-IVII

If your State does not have reliable data to complete an item on the application, or if you cannot get sufficient information to respond fully by the due date, do not leave the item blank. Instead, use one of these options:

Provide a clear explanation of your problem in obtaining the data.

Describe the alternative method of data collection you use.

Explain how you carry out the activity.

Whenever you have a problem completing an item, describe what kind of financial or technical assistance you would need to improve your response in future years.

Getting assistance in completing the application

If you have questions about programmatic issues, you may call CSAT’s Division of State and Community Assistance, Performance Partnership Grant Branch at (240) 276-2890 or CSAP’s Division of State and Community Assistance at (240) 276-2570 and ask for your respective State project officer or contact the State project officer directly by telephone or Internet e-mail using the directory provided (See Appendix A). If you have questions about Web-BGAS call 888-301-BGAS. If you have questions about fiscal or grants management issues, you may call the Grants Management Officer, Office of Program Services, Division of Grants Management, at (240) 276-1404.

SECTION I: IDENTIFYING INFORMATION AND ASSURANCES

This section of the application has three items:

1. Face Page (Form 1)

2. Table of Contents (Form 2)

3. Funding Agreements/Certifications (Form 3)

Assurances-Non-Construction Programs

Certifications

1. Face Page (Form 1)

This form is pre-numbered as page 3 in Web-BGAS. It requires the entry of identifying information and is self-explanatory. However, please take special note of the following:

• Item I, State Agency to be the Grantee for the Block Grant, requires both the name of the responsible agency designated by the Governor as the official grantee and the name of the organizational unit within that agency that administers the block grant.

• Item II, Contact Person for the Grantee of the Block Grant, requires identifying the person with overall responsibility for the block grant and providing contact information, including e-mail address.

• Item III, State Expenditure Period, is the most recent 12-month State expenditure period for which expenditure information is complete. This is probably the most recent State fiscal year that is closed out. When you submit next year for the FY 20098 award, your State Expenditure period will be the next consecutive 12-month period.

• Item IV, Date Submitted, is the calendar date on which the uniform block grant application is first submitted to SAMHSA.

• Item V, Contact Person Responsible for Application Submission, is the name of the individual to whom SAMHSA should address comments and/or questions concerning the content of the uniform block grant application.

Uniform Application for FY 20087 Substance Abuse Prevention and Treatment Block Grant
State Name:		DUNS Number:
I. State Agency to be the Grantee for the Block Grant
Agency Name:
Organization Unit:
Mailing Address:
City:	Zip Code:
II. Contact Person for the Grantee of the Block Grant
Name:
Agency Name:
Mailing Address:
City: 	Zip Code:
Telephone: 	Facsimile:
E-Mail:
III. State Expenditure Period
From:	To:
IV. Date Submitted
Date:	Original: Revision:
V. Contact Person Responsible for Application Submission
Name:	Telephone:
E-Mail:	Facsimile:

2. Table of Contents (Form 2)

The Table of Contents shows exactly how to assemble and order your application. If you are using Web-BGAS, Form 2 is a checklist that will help you see all the required Forms and checklists and those which have at least some data entered on them. Once all items listed on Form 2 are complete, a State need only read, print, sign, and mail Form 3, Assurances-Non-Construction Programs, and Certifications to complete their application.

If you are using a method other than Web-BGAS, complete the uniform application (checklists, forms, and narrative) and enter the page numbers as appropriate. Remember that every page in the application, including forms, must be consecutively numbered. The Table of Contents is pre-numbered and starts on page 2. . You shouldcan still use the Table of Contents as a checklist to ensure that your application is complete.

Form 2: FY 20087 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents
Item number	Form Description
I. Identifying Information and Assurances
11	Introduction
21	Face Page: Uniform Application for FY 20087 Substance Abuse Prevention and Treatment Block Grant (Form 1)
32	Table of Contents (Form 2)
43	Funding Agreements/Certifications
			I. Chief Executive Officer’s Funding Agreements/Certifications (Form 3)
			II. Certifications
			III. Assurances-Non-Construction Programs
			IV. Disclosure of Lobbying Activity
II. Annual Report, Progress Report and Plan Use of Substance Abuse Prevention and Treatment Block Grant Funds
1	FY 2005 SAPT Block Grant Reporting on the Federal Requirements: FY 2004 Annual Report; FY 2006 Progress Report; FY 2007 Intended Use Plan (narrative)
2	Reporting on the Federal Requirements: FY 2005 Annual Report; FY 2007 Progress Report; FY 2008 Intended Use Plan (narrative)
31	Goal 1: The State shall expend block grant funds to maintain a continuum of substance abuse treatment services that meet these needs for the services identified by the State.
42	Goal 2: An agreement to spend no less than 20 percent on primary prevention programs for individuals who do not require treatment for substance abuse, specifying the activities proposed for each of the six strategies.
53	Attachment A: Prevention (checklist)
64	Goal 3: An agreement to expend not less than an amount equal to the amount expended by the State for FY 1994 to establish new programs or expand the capacity of existing programs to make available treatment services designed for pregnant women and women with dependent children; and, directly or through arrangements with other public or nonprofit entities, to make available prenatal care to women receiving such treatment services, and, while the women are receiving services, child care.
75	Attachment B: Programs for Pregnant Women and Women with Dependent Children
86	Goal 4: An agreement to provide treatment to intravenous drug abusers that fulfills the 90 percent capacity reporting, 14-120 day performance requirement, interim services, outreach activities and monitoring requirements.
97	Attachment C: Programs for Intravenous Drug Users (IVDUs)
108	Attachment D: Program Compliance Monitoring
119	Goal 5: An agreement, directly or through arrangements with other public or nonprofit private entities, to routinely make available tuberculosis services to each individual receiving treatment for substance abuse and to monitor such service delivery.
	(Table of Contents continues on following pages.)
Form 2: FY 2008 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description
120	Goal 6: An agreement, by designated States, to provide treatment for persons with substance abuse problems with an emphasis on making available within existing programs early intervention services for HIV in areas of the State that have the greatest need for such services and to monitor such service delivery.
	(Table of Contents continues on following pages.)
FY 20087 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description
II. Use of Substance Abuse Prevention and Treatment Block Grant Funds (continued)
131	Attachment E: Tuberculosis (TB) and Early Intervention Services for HIV
142	Goal 7: An agreement to continue to provide for and encourage the development of group homes for recovering substance abusers through the operation of a revolving loan fund.
153	Attachment F: Group Home Entities and Programs
164	Goal 8: An agreement to continue to have in effect a State law that makes it unlawful for any manufacturer, retailer, or distributor of tobacco products to sell or distribute any such product to any individual under the age of 18; and, to enforce such laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under age 18.
175	Goal 9: An agreement to ensure that each pregnant woman be given preference in admission to treatment facilities; and, when the facility has insufficient capacity, to ensure that the pregnant woman be referred to the State, which will refer the woman to a facility that does have capacity to admit the woman, or if no such facility has the capacity to admit the woman, will make available interim services within 48 hours, including a referral for prenatal care.
186	Attachment G: Capacity Management and Waiting List Systems
197	Goal 10: An agreement to improve the process in the State for referring individuals to the treatment modality that is most appropriate for the individual.
2018	Goal 11: An agreement to provide continuing education for the employees of facilities which provide prevention activities or treatment services.
2119	Goal 12: An agreement to coordinate prevention activities and treatment services with the provision of other appropriate services.
2220	Goal 13: An agreement to submit an assessment of the need for both treatment and prevention in the State for authorized activities, both by locality and by the State in general.
231	Goal 14: An agreement to ensure that no program funded through the block grant will use funds to provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs.
242	Goal 15: An agreement to assess and improve, through independent peer review, the quality and appropriateness of treatment services delivered by providers that receive funds from the block grant.
253	Attachment H: Independent Peer Review
24	Goal 16: An agreement to ensure that the State has in effect a system to protect patient records from inappropriate disclosure.
		(Table of Contents continues on following pages.)
Form 2: FY 2008 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description
26	Goal 16: An agreement to ensure that the State has in effect a system to protect patient records from inappropriate disclosure.
275	Goal 17: An agreement to ensure that the State has in effect a system to comply with 42 U.S.C. 300x-65 and 42 C.F. R. part 54.
286	Attachment I: Charitable Choice
		(Table of Contents continues on following pages.)
FY 20087 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description
II. Use of Substance Abuse Prevention and Treatment Block Grant Funds (continued)
297	Attachment J: Waivers
3028	Substance Abuse State Agency Spending Report (Form 4)
3129	Primary Prevention Expenditures Checklist (Form 4a and 4b)
320	Resource Development Expenditure Checklist (Form 4cb)
31	Substance Abuse Entity Inventory
3312	Substance Abuse Entity Inventory Entity Inventory (Form 6)
3423	Prevention Strategy Report Risk Strategies (Form 6aA)
3534	Treatment Utilization Matrix (Form 7aA) Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services (Form 7B)
36	Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services (Form 7b)
374	Description of Base Calculations
385.i-iv.	Maintenance of Effort (MOE) Tables: (Single State Agency [SSA] MOE, TB MOE, HIV MOE, and Women’s Base). (Tables I-IV)
III. State Needs -Intended Use of FY 20087 Substance Abuse Prevention and Treatment Block Grant Funds
1	Planning (narrative)
2	Criteria for allocating funds (checklist)
3	Treatment Needs Assessment Summary Matrix (Form 8)
4	Treatment needs by age, sex, and race/ethnicity (Form 9)How Your State Determined the Form 8 Estimates
5	How Your State Determined the Form 8 and 9 Estimates Treatment needs by age, sex, and race/ethnicity (Form 9)
6	Intended use plan
7	Intended Use Plan (Form 11)
8	Primary Prevention Planned Expenditure Checklist (Form 11a and 11b)
9	Resource Development Planned Expenditure Checklist (Form 11cb)
10	Treatment Capacity
101	Treatment Capacity Matrix (Form 12)
12	Purchasing Services
13	Methods for purchasing (checklist)
14	Methods for determining prices (checklist)
	(Table of Contents continues on following page.)

Form 2: FY 2008 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description
11	Purchasing Services ; Methods for purchasing (checklist)
12	Purchasing Services ; Methods for determining prices (checklist)
135	Program Performance Monitoring (checklist)
	(Table of Contents continues on following page.)

FY 2007 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item Number		Form Description
IV A. VOLUNTARY TREATMENT PERFORMANCE MEASURES
1	Form T1-Employment Status (from Admission to Discharge)
2	Form T2-Homelessness: Living Status (from Admission to Discharge)
3	Form T3-Criminal Justice Involvement (from Admission to Discharge)
4	Form T4-Change in Abstinence: Alcohol Use (from Admission to Discharge)
5	Form T5-Change in Abstinence: Other Drug Use (from Admission to Discharge)
6	Form T6-Change in Social Support of Recovery (from Admission to Discharge)
7	Form T7-Retention: Length of Stay (in Days) of Clients Completing Treatment
IV B. VOLUNTARY PREVENTION PERFORMANCE MEASURES
1	Form P1-NOMs Domain: Reduced Morbidity—Measure: 30 Day UsePerception of Risk/Harm of UseNumber of Persons Served
2	Form P2-NOMs Domain: Reduced Morbidity—Measure: Perception of Risk/Harm of UseNumber of Evidence-Based Programs, Practices, and Policies
3	Form P3-NOMs Domain: Reduced Morbidity—Measure: Age of First UsePerception of Risk/Harm of and Unfavorable Attitudes Towards Substance Use by Those Under Age 21
4	Form P4-NOMs Domain: Reduced Morbidity—Measure: Perception of Disapproval/AttitudesUse of Substances During the Past 30 Days
5	Form P5-NOMs Domain: Employment/Education—Measure: Perception of Workplace Policy
6	Form P6-NOMs Domain: Employment/Education—Measure: ATOD-Related Suspensions and Expulsions (Developmental)
7	Form P7-NOMs Domain: Employment/Education—Measure: Average Daily School Attendance Rate
8	Form P8- NOMs Domain: Crime and Criminal Justice—Measure: Alcohol-Related Traffic Fatalities
9	Form P9-NOMs Domain: Crime and Criminal Justice—Measure: Alcohol- and Drug-Related Arrests
10	Form P10-NOMs Domain: Social Connectedness—Measure: Family Communications Around Drug and Alcohol Use
11	Form P11-NOMs Domain: Retention—Measure: Youth Seeing, Reading, Watching, or Listening to a Prevention Message
12	Form P12a and 12b-Number of Persons Served by Age, Race, and Ethnicity—NOMs Domain: Access/Capacity—Measure: Persons Served by Age, Race, and Ethnicity
	(Table of Contents continues on following page.)
Form 2: FY 2008 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description
12	Form P12a and 12b-Number of Persons Served by Age, Gender, Race, and Ethnicity—NOMs Domain: Access/Capacity—Measure: Persons Served by Age, Gender, Race, and Ethnicity
13	Form P13-Number of Persons Served by Type of Intervention—NOMs Domain: Access/Capacity—Measure: Persons Served by Type of Intervention
14	Form P14-Evidence-Based Programs and Strategies by Type of Intervention—NOMs Domain: Retention—NOMs Domain: Use of Evidence-Based Programs—Measure: Evidence-Based Programs and Strategies
135	Form P13-Number of Persons Served by Type of Intervention—NOMs Domain: Access/Capacity—Measure: Persons Served by Type of Intervention
146	Form P14-Evidence-Based Programs and Strategies by Type of Intervention—NOMs Domain: Retention—NOMs Domain: Use of Evidence-Based Programs—Measure: Evidence-Based Programs and Strategies
13	Form P13-Number of Persons Served by Type of Intervention—NOMs Domain: Access/Capacity—Measure: Persons Served by Type of Intervention
14	Form P14-Evidence-Based Programs and Strategies by Type of Intervention—NOMs Domain: Retention—NOMs Domain: Use of Evidence-Based Programs—Measure: Evidence-Based Programs and Strategies
175	Form P15-Services Provided Within Cost Bands—NOMs Domain: Cost Effectiveness—Measure: Services Provided Within Cost Bands

3. Funding Agreements/Certifications

The following three standard forms (I, II, and III) must be signed by the Chief Executive Officer or an authorized designee and submitted with this application. The Disclosure of Lobbying Activity form must be signed, if applicable. Documentation authorizing a designee must be attached to the application as an appendix.

I. Chief Executive Officer’s Funding Agreements/Certifications (Form 3)

II. Certifications

Certifications 1-5 are included on OMB approved form, OMB approval # 0920-0428 which requires one signature.

1. Certification Regarding Debarment and Suspension

2. Certification Regarding Drug-Free Workplace Requirements

This certification is included in the application package. It has to be submitted only if a Statewide or agency-wide annual assurance has not been submitted to DHHS.

3. Certifications Regarding Lobbying

This certification, included in the application package, must be signed and submitted before the award of any Federal grant or cooperative agreement exceeding $100,000.

4. Certification Regarding Program Fraud Civil Remedies Act (PFCRA)

5. Certification Regarding Environmental Tobacco Smoke

III. Assurances-Non-Construction Programs

IV. Disclosure of Lobbying Activities

Standard Form LLL and LLL-A need only to be signed and completed only if the grantee has undertaken any lobbying during the 12 month State expenditure period designated on Form 1.

Completion of Form SF-LLL is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate.

Uniform Application for FY 20087 Substance Abuse Prevention and Treatment Block Grant

Funding Agreements/Certifications

as Required by the Public Health Service (PHS) Act

As part of the annual application for Block Grant funds, it is required under Title XIX, Part B, Subpart II of the Public Health Services Ac The PHS Act, as amended, requires the chief executive officer (or an authorized designee) of the applicant organization to certify that the State will comply with the following specific citations as summarized and set forth below, and with any regulations or guidelines issued in conjunction with this Subpart except as exempt by statute.

We will accept a signature on this form as certification of agreement to comply with the cited provisions of the PHS Act. If signed by a designee, a copy of the designation must be attached.

I. Formula Grants to States, Section 1921

Grant funds will be expended “only for the purpose of planning, carrying out, and evaluating activities to prevent and treat substance abuse and for related activities” as authorized.

II. Certain Allocations, Section 1922

• Allocations Regarding Primary Prevention Programs, Section 1922(a)

• Allocations Regarding Women, Section 1922(b)

III. Intravenous Drug Abuse, Section 1923

• Capacity of Treatment Programs, Section 1923(a)

• Outreach Regarding Intravenous Substance Abuse, Section 1923(b)

IV. Requirements Regarding Tuberculosis and Human Immunodeficiency Virus, Section 1924

V. Group Homes for Recovering Substance Abusers, Section 1925

Optional beginning FY 2001 and subsequent fiscal years. Territories as described in Section 1925(c) are exempt.

The State “has established, and is providing for the ongoing operation of a revolving fund” in accordance with Section 1925 of the PHS Act, as amended. This requirement is now optional.

VI. State Law Regarding Sale of Tobacco Products to Individuals Under Age of 18, Section 1926:

• The State has a law in effect making it illegal to sell or distribute tobacco products to minors as provided in Section 1926 (a)(1).

• The State will enforce such law in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under the age of 18 as provided in Section 1926 (b)(1).

• The State will conduct annual, random unannounced inspections as prescribed in Section 1926 (b)(2).

VII. Treatment Services for Pregnant Women, Section 1927

The State “…will ensure that each pregnant woman in the State who seeks or is referred for and would benefit from such services is given preference in admission to treatment facilities receiving funds pursuant to the grant.”

VIII. Additional Agreements, Section 1928

• Improvement of Process for Appropriate Referrals for Treatment, Section 1928(a)

• Continuing Education, Section 1928(b)

• Coordination of Various Activities and Services, Section 1928(c)

• Waiver of Requirement, Section 1928(d)

IX. Submission to Secretary of Statewide Assessment of Needs, Section 1929

X. Maintenance of Effort Regarding State Expenditures, Section 1930

With respect to the principal agency of a State, the State “will maintain aggregate State expenditures for authorized activities at a level that is not less than the average level of such expenditures maintained by the State for the 2-year period preceding the fiscal year for which the State is applying for the grant.”

XI. Restrictions on Expenditure of Grant, Section 1931

XII. Application for Grant; Approval of State Plan, Section 1932

XIII. Opportunity for Public Comment on State Plans, Section 1941

The plan required under Section 1932 will be made “public in such a manner as to facilitate comment from any person (including any Federal person or any other public agency) during the development of the plan (including any revisions) and after the submission of the plan to the Secretary.”

XIV. Requirement of Reports and Audits by States, Section 1942

XV. Additional Requirements, Section 1943

XVI. Prohibitions Regarding Receipt of Funds, Section 1946

XVII. Nondiscrimination, Section 1947

XVIII. Services Provided By Nongovernmental Organizations, Section 1955

I hereby certify that the State or Territory will comply with Title XIX, Part B, Subpart II and Subpart III of the Public Health Service Act, as amended, as summarized above, except for those Sections in the Act that do not apply or for which a waiver has been granted or may be granted by the Secretary for the period covered by this agreement.

State:

Name of Chief Executive Officer or Designee:

Signature of CEO or Designee:

Title: Date Signed:

If signed by a designee, a copy of the designation must be attached

1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION The undersigned (authorized official signing for the applicant organization) certifies to the best of his or her knowledge and belief, that the applicant, defined as the primary participant in accordance with 45 CFR Part 76, and its principals: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal Department or agency; (b) have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and (d) have not within a 3-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default. Should the applicant not be able to provide this certification, an explanation as to why should be placed after the assurances page in the application package. The applicant agrees by submitting this proposal that it will include, without modification, the clause titled "Certification Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion – Lower Tier Covered Transactions" in all lower tier covered transactions (i.e., transactions with sub-grantees and/or contractors) and in all solicitations for lower tier covered transactions in accordance with 45 CFR Part 76.	2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS The undersigned (authorized official signing for the applicant organization) certifies that the applicant will, or will continue to, provide a drug-free work-place in accordance with 45 CFR Part 76 by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dis-pensing, possession or use of a controlled substance is prohibited in the grantee’s work-place and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing an ongoing drug-free awareness program to inform employees about – (1) The dangers of drug abuse in the workplace; (2) The grantee’s policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a) above; (d) Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment under the grant, the employee will – (1) Abide by the terms of the statement; and (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; (e) Notifying the agency in writing within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;
(f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with respect to any employee who is so convicted – (1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). For purposes of paragraph (e) regarding agency notification of criminal drug convictions, the DHHS has designated the following central point for receipt of such notices: Office of Grants and Acquisition Management Office of Grants Management Office of the Assistant Secretary for Management and Budget Department of Health and Human Services 200 Independence Avenue, S.W., Room 517-D Washington, D.C. 20201 3. CERTIFICATION REGARDING LOBBYING Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the Federal Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying undertaken with non-Federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93). The undersigned (authorized official signing for the applicant organization) certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the under signed, to any 5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children’s services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children’s services provided in private residence, portions of facilities used for inpatient drug or alcohol treatment, service providers whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.	person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities, "in accordance with its instructions. (If needed, Standard Form-LLL, "Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this application form.) (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA) The undersigned (authorized official signing for the applicant organization) certifies that the statements herein are true, complete, and accurate to the best of his or her knowledge, and that he or she is aware that any false, fictitious, or fraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The undersigned agrees that the applicant organization will comply with the Public Health Service terms and conditions of award if a grant is awarded as a result of this application. By signing the certification, the undersigned certifies that the applicant organization will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The applicant organization agrees that it will require that the language of this certification be included in any subawards which contain provisions for children’s services and that all subrecipients shall certify accordingly. The Public Health Services strongly encourages all grant recipients to provide a smoke-free workplace and promote the non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL	TITLE
APPLICANT ORGANIZATION		DATE SUBMITTED

DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure.)

1. Type of Federal Action:

2. Status of Federal Action

3. Report Type:

 

a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance

 

a. bid/offer/application b. initial award c. post-award

 

a. initial filing b. material change

For Material Change Only:

Year

     

Quarter

     

date of last report

     

4. Name and Address of Reporting Entity:

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Prime Subawardee

     

Tier

     

, if known:

     

     

Congressional District, if known:

     

Congressional District, if known:

     

6. Federal Department/Agency:

7. Federal Program Name/Description:

     

     

CFDA Number, if applicable:

     

8. Federal Action Number, if known:

9. Award Amount, if known:

     

$      

10. a. Name and Address of Lobbying Entity (if individual, last name, first name, MI):

b. Individuals Performing Services (including address if different from No. 10a.) (last name, first name, MI):

     

     

11. Information requested through this form is authorized by title 31 U.S.C. Ssection 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Print Name:

     

Title:

     

Telephone No.:

     

Date:

     

Federal Use Only:

     

Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97)

DISCLOSURE OF LOBBYING ACTIVITIES CONTINUATION SHEET
Reporting Entity:	     		Page	     	of	     
     

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. Section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks “subawardee”, then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known.

6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 [e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency]. Include prefixes, e.g., ‘‘RFP-DE-90-001.’’

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a).

Enter Last Name, First Name, and Middle Initial (MI).

11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is OMB No.0348-0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.

ASSURANCES – NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant I certify that the applicant:
1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standard or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM’s Standard for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L.88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685- 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §§794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age;			(e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to non- discrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Title II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327- 333), regarding labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetland pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Costal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.		13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§ 469a-1 et seq.). 14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL	TITLE
	     
APPLICANT ORGANIZATION				DATE SUBMITTED
     				     

SECTION II: ANNUAL REPORT, PROGRESS REPORT AND PLAN

ACTUAL USE OF FY 2005, PROGRESS REPORT ON FY 2007 AND PLAN FOR FY 2008 PROGRAM ACTIVITIES4

SAPT BLOCK GRANT FUNDS

This section documents how the State used the FY 20054 award to meet the goals, objectives, and activities described in the application for those funds, how the State is using it FY 20076 award currently and how the State will address these requirements as it expends FY 2008 funds.. Therefore, it is helpful to review the FY 2005 and FY 2007 4 applications (and any modifications or revisions that may have been made) before you complete this section. This information is required by section 1942 of the Public Health Service (PHS) Act (See 42 U.S.C. 300x-52). It addresses the report requirements of the SAPT Block Grant.. If you are using Web-BGAS, its ordering and formatting will be comparable to the MS Word version of this guidance.

Section II refers to the statutory and regulatory requirements of the PHS Act, as amended (See 42 U.S.C. 300x-21 et. seq. and 45 C.F.R. Part 96).

By the time you complete this report, the State will have spent the FY 20054 block grant award. Therefore, all financial data requested should be available to you.

This section has five items. It requires completing four checklists, addressing the 17 Federal Goals for the FY 20054, 20076, and 20087 narratives, five forms, and four tables. Here is an overview of the requirements.

	Item	What you need to submit
1.	FY 20054 SAPT Block Grant	Authorized Allocation
2.	How substance abuse funds were used: FY 20054 Annual Report; FY 20076 Progress Report; FY 20087 Intended Use; and Attachments (A-J).	Narrative, Form 4 and four checklists
3.	Entity Inventory; Prevention Strategy Report	Form 6 and Form 6aA
4.	Treatment Utilization Matrix; Number of Persons Served for Alcohol and Other Drug Use in State-Funded Services By Age, Sex, and Race/Ethnicity (Unduplicated Count)	Form 7aA and Form 7bB
5.	Maintenance of Effort (MOE) Tables: Total Single State Agency Expenditures for Substance Abuse; Statewide Non-Federal Expenditures for Tuberculosis Services for Substance Abusers in Treatment; Statewide Non-Federal Expenditures for HIV Early Intervention Services to Substance Abusers in Treatment; and Expenditures for Services to Pregnant Women and Women With Dependent Children (Maintenance)	Tables I – IV

1. FY 20054 SAPT Block Grant.

Your annual SAPT Block Grant Award $________ for FY 20054 is reflected on line 8 of the Notice of Block Grant Award. If you use Web-BGAS the data will be entered automatically for you.

2. How substance abuse funds were used and intended (narrative).

NARRATIVES (FEDERAL GOALS FY 20054, FY 20076, AND FY 20087) AND ATTACHMENTS

Except for Federal Goal 8 and optional Federal Goal 7, narratives for the Federal Goals must be addressed for FY 20054, 20076, and 20087 under each Federal Goal respectively.

In addressing Federal Goal 8, indicate whether or not the FY 20087 Synar report (See 42 U.S.C. 300x-26) is included with the FY 20087 uniform application. If the answer is no, indicate when the State plans to submit the report.

In addressing each of the the Federal Goals for FY 20054 describe, in a brief narrative, how the SAPT Block Grant funds were used to meet the treatment and primary prevention goals, objectives, and activities spelled out in the State’s FY 20054 application. Be sure to specify the primary prevention activities performed for each of the six strategies or using the Institute of Medicine (IOM) prevention classifications of Universal, Selective, and Indicated.. Include a description of the State’s policies, procedures, and laws regarding substance abuse treatment, and information on what programs and activities were supported, what services were provided, and what progress was made (See 42 U.S.C. 300x-52 and 45 C.F.R. 96.122(f)(1)(ii)).

In addressing each of the Federal Goals for FY 20076, provide a description of the State’s progress in meeting the treatment and primary prevention goals, objectives, and activities included in the FY 20076 application and a brief description of the recipients of block grant funds. For primary prevention, the description should also address the State’s progress in performing the activities for the six strategies or using the Institute of Medicine (IOM) prevention classifications of Universal, Selective, and Indicated. articulated in the FY 20076 application, as well (See 42 U.S.C. 300x-52 and 45 C.F.R. 96.122(f)(5)(i)).

In addressing each of the Federal Goals for FY 20087, describe the State’s intended use of block grant funds and the specific treatment and primary prevention goals, objectives, and activities the State will carry out to achieve these objectives. At a minimum, eachthe narrative must address the following:

In an effort to provide more concrete guidance on the essential points that must be covered in the narratives, the following questions must be addressed when responding to each.

(1) Who will be served – describe the target population and provide an estimate of the number of persons to be served in the target population;

(2) What activities/services will be provided, expanded, or enhanced – this may include activities/services by treatment modality or prevention strategy;

(3) When will the activities/services be implemented (date) – for ongoing activities/services, include information on the progress toward meeting the goals including dates on which integral activities/services began or will begin;

(4) Where in the State (geographic area) will the activities/services be undertaken – this may include counties, districts, regions, or cities;

5. How will the activities/services be operationalized – this may be through direct

procurement, subcontractors or grantees, or intra governmental agreements.

As an example, in response to the narrative on planned activities/services regarding the expansion of existing or creation of new programs for pregnant women and women with dependent children, a State might provide the following information:

“It is planned in FY 20087 to provide residential treatment services to 200 women with dependent children. In addition to providing residential treatment for women, facilities will be provided to allow the housing of minor children during the course of the treatment episode. This program is scheduled to be implemented in May 20087 in the four counties of the State that have the highest prevalence of substance abuse among women. We intend to fund this activity through a competitive contract with licensed, accredited providers in the four counties.”

To complete the 17 Federal goals, objectives, and activities for the intended use plan, please address the Federal block grant requirements in a separate section first and then you may add an additional section describing other State requirements. List the specific objectives under each requirement and goal in priority order. Describe what activities the State plans to undertake to achieve these objectives. Include key elements in the State’s strategy to improve existing programs, create new ones, and remove barriers to improvement and expansion. Keep your discussion of each goal or requirement, its objectives, and activities to no more than one page per reporting year addressed (i.e., FY 2005, 2007, and 2008).

The application requires 10 attachments (A-J). These are in narrative or checklist form and follow the related Federal goals below.

GOAL # 1. The State shall expend block grant funds to maintain a continuum of substance abuse treatment services that meet these needs for the services identified by the State. Describe the continuum of block grant-funded treatment services available in the State (See 42 U.S.C. 300x-21(b) and 45 C.F.R. 96.122(f)(g)).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 2. An agreement to spend not less than 20 percent on primary prevention programs for individuals who do not require treatment for substance abuse, specifying the activities proposed for each of the six strategies or by the Institute of Medicine Model of Universal, Selective, or Indicated as defined below: (See 42 U.S.C. 300x-22(ab)(1) and 45 C.F.R. 96.124(b)(1)).

Institute of Medicine Classification: Universal Selective and Indicated:

• Universal: Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct interventions directly serve participants who have not been identified on the basis of individual risk.

• Universal Indirect interventions support population-based activities and the provision of information and technical assistance.

• Universal Direct. Row 1—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, after school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions)

• Universal Indirect. Row 2—Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels. (Adapted from The Institute of Medicine Model of Prevention)

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

Attachment A: Prevention

Answer the following questions about the current year status of policies, procedures, and legislation in your State. Most of the questions are related to Healthy People 2010 objectives. References to these objectives are provided for each applicable question. To respond, check the appropriate box or enter numbers on the blanks provided. After you have completed your answers, copy the attachment and submit it with your application.

1. Does your State conduct sobriety checkpoints on major and minor thoroughfares on a periodic basis? (HP 26-25)

 Yes  No  Unknown

2. Does your sState conduct or fund prevention/education activities aimed at preschool children? (HP 26-9)

 Yes  No  Unknown

3. Does your State alcohol and drug agency conduct or fund prevention/education activities in every school district aimed at youth grades K-12? (HP 26-9)

SAPT BLOCK GRANT	OTHER STATE FUNDS	DRUG FREE SCHOOLS
 Yes  No  Unknown	 Yes  No  Unknown	 Yes  No  Unknown

4. Does your State have laws making it illegal to consume alcoholic beverages on the campuses of State colleges and universities? (HP 26-11)

 Yes  No  Unknown

5. Does your State conduct prevention/education activities aimed at college students that include: (HP 26-11c)

Education bureau?  Yes  No  Unknown

Dissemination of materials?  Yes  No  Unknown

Media campaigns?  Yes  No  Unknown

Product pricing strategies?  Yes  No  Unknown

Policy to limit access?  Yes  No  Unknown

6. Does your State now have laws that provide for administrative suspension or revocation of drivers’ licenses for those determined to have been driving under the influence of intoxicants? (HP 26-24)

 Yes  No  Unknown

7. Has the State enacted and enforced new policies in the last year to reduce access to alcoholic beverages by minors such as (HP 26-11c, 12, 23):

Restrictions at recreational and entertainment events at which youth made up a majority of participants/consumers?

 Yes  No  Unknown

New product pricing?

 Yes  No  Unknown

New taxes on alcoholic beverages?

 Yes  No  Unknown

New laws or enforcement of penalties and license revocation for sale of alcoholic beverages to minors?

 Yes  No  Unknown

Parental responsibility laws for a child’s possession and use of alcoholic beverages?

 Yes  No  Unknown

8. Does your State provide training and assistance activities for parents regarding alcohol, tobacco, and other drug use by minors?

 Yes  No  Unknown

9. What is the average age of first use for the following? (HP 26-9 and 27-4, if available)

Age 0-5 Age 6-11 Age 12-14 Age 15-18

Cigarettes

Alcohol

Marijuana

10. What is your State’s present legal alcohol concentration tolerance level for: (HP 26-25)

Motor vehicle drivers age 21 and older?

Motor vehicle drivers under age 21?

11. How many communities in your State have comprehensive, community-wide coalitions for alcohol and other drug abuse prevention (HP 26-3)? ________

12. Has your State enacted statutes to restrict promotion of alcoholic beverages and tobacco that are focused principally on young audiences, (HP 26-11 and 26-16)?

 Yes  No  Unknown

GOAL # 3. An agreement to expend not less than an amount equal to the amount expended by the State for FY 1994 to establish new programs or expand the capacity of existing programs to make available treatment services designed for pregnant women and women with dependent children; and, directly or through arrangements with other public or nonprofit entities, to make available prenatal care to women receiving such treatment services, and, while the women are receiving services, child care (See 42 U.S.C. 300x-22(b)(1)(C) and 45 C.F.R. 96.124(c)(e)).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

Attachment B: Programs for Pregnant Women and Women with Dependent Children

(See 42 U.S.C. 300x-22(b); 45 C.F.R. 96.124(c)(3); and 45 C.F.R. 96.122(f)(1)(viii))

For the fiscal year three years prior (FY 20054) to the fiscal year for which the State is applying for funds:

Refer back to your Substance Abuse Entity Inventory (Form 6). Identify those projects serving pregnant women and women with dependent children and the types of services provided in FY 20054. In a narrative of up to two pages, describe these funded projects.

The PHS Act required the State to expend at least 5 percent of the FY 1993 and FY 1994 block grants to increase (relative to FY 1992 and FY 1993, respectively) the availability of treatment services designed for pregnant women and women with dependent children. In the case of a grant for any subsequent fiscal year, the State will expend for such services for such women not less than an amount equal to the amount expended by the State for fiscal year 1994.

In up to four pages, answer the following questions:

1. Identify the name, location (include sub-State planning area), Inventory of Substance Abuse Treatment Services (I-SATS) ID number (formerly the National Facility Register (NFR) number), level of care (refer to definitions in Section II.4), capacity, and amount of funds made available to each program designed to meet the needs of pregnant women and women with dependent children.

2. What did the State do to ensure compliance with 42 U.S.C. 300x-22(b)(1)(C) in spending FY 20054 block grant and/or State funds?

3. What special methods did the State use to monitor the adequacy of efforts to meet the special needs of pregnant women and women with dependent children?

4. What sources of data did the State use in estimating treatment capacity and utilization by pregnant women and women with dependent children?

5. What did the State do with FY 20054 block grant and/or State funds to establish new programs or expand the capacity of existing programs for pregnant women and women with dependent children?

GOAL # 4. An agreement to provide treatment to intravenous drug abusers that fulfills the 90 percent capacity reporting, 14-120 day performance requirement, interim services, outreach activities and monitoring requirements (See 42 U.S.C. 300x-23 and 45 C.F.R. 96.126).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

Attachment C: Programs for Intravenous Drug Users (IVDUs)

(See 42 U.S.C. 300x-23; 45 C.F.R. 96.126; and 45 C.F.R. 96.122(f)(1)(ix))

For the fiscal year three years prior (FY 20054) to the fiscal year for which the State is applying for funds:

1. How did the State define IVDUs in need of treatment services?

2. What did the State do to ensure compliance with 42 U.S.C. 300x-23 of the PHS Act as such sections existed after October 1, 1992, in spending FY 2004 SAPT Block Grant funds (See 45 C.F.R. 96.126(a))?

3. What did the State do to ensure compliance with 42 U.S.C. 300x-31(a)(1)(F) of the PHS Act prohibiting the distribution of sterile needles for injection of any illegal drug (See 45 C.F.R. 96.135(a)(6))?

24. 42 U.S.C. 300x-23(a)(1) requires that any program receiving amounts from the grant to provide treatment for intravenous drug abuse notify the State when the program has reached 90 percent of its capacity. Describe how the State ensured that this was done. Please provide a list of all such programs that notified the State during FY 20054 and include the program’s I-SATS ID number (See 45 C.F.R. 96.126(a)).

35. 42 U.S.C. 300x-23(a)(2)(A)(B) requires that an individual who requests and is in need of treatment for intravenous drug abuse is admitted to a program of such treatment within 14-120 days. Describe how the State ensured that such programs were in compliance with the 14-120 day performance requirement (See 45 C.F.R. 96.126(b)).

46. 42 U.S.C. 300x-23(b) requires any program receiving amounts from the grant to provide treatment for intravenous drug abuse to carry out activities to encourage individuals in need of such treatment to undergo treatment. Describe how the State ensured that outreach activities directed toward IVDUs was accomplished (See 45 C.F.R. 96.126(e)).

Attachment D: Program Compliance Monitoring

(See 45 C.F.R. 96.122(f)(3)(vii))

The Interim Final Rule (45 C.F.R. Part 96) requires effective strategies for monitoring programs’ compliance with the following sections of the PHS Act: 42 U.S.C. 300x-23(a); 42 U.S.C. 300x-24(a); and 42 U.S.C. 300x-27(b).

For the fiscal year two years prior (FY 20065) to the fiscal year for which the State is applying for funds:

In up to three pages provide the following:

• A description of the strategies developed by the State for monitoring compliance with each of the sections identified below:; and

• A description of the problems identified and corrective actions taken:

1. Notification of Reaching Capacity 42 U.S.C. 300x-23(a)

(See 45 C.F.R. 96.126(f) and 45 C.F.R. 96.122(f)(3)(vii));

2. Tuberculosis Services 42 U.S.C. 300x-24(a)

(See 45 C.F.R. 96.127(b) and 45 C.F.R. 96.122(f)(3)(viii)); and

3. Treatment Services for Pregnant Women 42 U.S.C. 300x-27(b)

(See 45 C.F.R. 96.131(f) and 45 C.F.R. 96.122(f)(3)(vii)).

• A description of the problems identified and corrective actions taken.

GOAL # 5. An agreement, directly or through arrangements with other public or nonprofit private entities, to routinely make available tuberculosis services to each individual receiving treatment for substance abuse and to monitor such service delivery (See 42 U.S.C. 300x-24(a) and 45 C.F.R. 96.127).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 6. An agreement, by designated States, to provide treatment for persons with substance abuse problems with an emphasis on making available within existing programs early intervention services for HIV in areas of the State that have the greatest need for such services and to monitor such service delivery (See 42 U.S.C. 300x-24(b) and 45 C.F.R. 96.128).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

Attachment E: Tuberculosis (TB) and Early Intervention Services for HIV

(See 45 C.F.R. 96.122(f)(1)(x))

For the fiscal year three years prior (FY 20054) to the fiscal year for which the State is applying for funds:

Provide a description of the State’s procedures and activities and the total funds expended (or obligated if expenditure data is not available) for tuberculosis services. If a “designated State,” provide funds expended (or obligated), for early intervention services for HIV.

Examples of procedures include, but are not limited to:

• development of procedures (and any subsequent amendments), for tuberculosis services and, if a designated State, early intervention services for HIV, e.g., Qualified Services Organization Agreements (QSOA) and Memoranda of Understanding (MOU);

• the role of the single State authority (SSA) for substance abuse prevention and treatment; and

• the role of the single State authority for public health and communicable diseases.

Examples of activities include, but are not limited to:

• the type and amount of training made available to providers to ensure that tuberculosis services are routinely made available to each individual receiving treatment for substance abuse;

• the number and geographic locations (include sub-State planning area) of projects delivering early intervention services for HIV;

• the linkages between IVDU outreach (See 42 U.S.C. 300x-23(b) and 45 C.F.R. 96.126(e)) and the projects delivering early intervention services for HIV; and

• technical assistance.

GOAL # 7. An agreement to continue to provide for and encourage the development of group homes for recovering substance abusers through the operation of a revolving loan fund (See 42 U.S.C. 300x-25 and 45 C.F.R. 96.129). Effective FY 2001, the States may choose to maintain such a fund. If a State chooses to participate, reporting is required.

FY 20054 (Compliance): (participation OPTIONAL)

FY 20076 (Progress): (participation OPTIONAL)

FY 20087 (Intended Use): (participation OPTIONAL)

Attachment F: Group Home Entities and Programs

(See 42 U.S.C. 300x-25; 45 C.F.R. 96.129; and 45 C.F.R. 96.122(f)(1)(vii))

If the State has chosen in Ffiscal Yyear (FY) 20054 to participate and continue to provide for and encourage the development of group homes for recovering substance abusers through the operation of a revolving loan fund then Attachment F must be completed.

Provide a list of all entities that have received loans from the revolving fund during FY 20054 to establish group homes for recovering substance abusers. In a narrative of up to two pages, describe the following:

• the number and amount of loans made available during the applicable fiscal years;

• the amount available in the fund throughout the fiscal year;

• the source of funds used to establish and maintain the revolving fund;

• the loan requirements, application procedures, the number of loans made, the number of repayments, and any repayment problems encountered;

• the private, nonprofit entity selected to manage the fund;

• any written agreement that may exist between the State and the managing entity;

• how the State monitors fund and loan operations; and

• any changes from previous years’ operations.

GOAL # 8. An agreement to continue to have in effect a State law that makes it unlawful for any manufacturer, retailer, or distributor of tobacco products to sell or distribute any such product to any individual under the age of 18; and, to enforce such laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under age 18 (See 42 U.S.C. 300x-26, and 45 C.F.R. 96.130 and 45 C.F.R. 96.122(d))).

• Is the State’s FY 20087 Annual Synar Report included with the FY 20087 uniform application?

Yes No

• If No, please indicate when the State plans to submit the report:

mm/dd/20076

Note: The statutory due date is December 31, 20076.

GOAL # 9. An agreement to ensure that each pregnant woman be given preference in admission to treatment facilities; and, when the facility has insufficient capacity, to ensure that the pregnant woman be referred to the State, which will refer the woman to a facility that does have capacity to admit the woman, or if no such facility has the capacity to admit the woman, will make available interim services within 48 hours, including a referral for prenatal care (See 42 U.S.C. 300x-27 and 45 C.F.R. 96.131).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

Attachment G: Capacity Management and Waiting List Systems

(See 45 C.F.R. 96.122(f)(3)(vi))

For the fiscal year two years prior (FY 20065) to the fiscal year for which the State is applying for funds:

In up to five pages, provide a description of the State’s procedures and activities undertaken, and the total amount of funds expended (or obligated if expenditure data is not available), to comply with the requirement to develop capacity management and waiting list systems for intravenous drug users and pregnant women (See 45 C.F.R. 96.126(c) and 45 C.F.R. 96.131(c), respectively). This report should include information regarding the utilization of these systems. Examples of procedures may include, but not be limited to:

• development of procedures (and any subsequent amendments) to reasonably implement a capacity management and waiting list system;

• the role of the Single State Authority (SSA) for substance abuse prevention and treatment;

• the role of intermediaries (county or regional entity), if applicable, and substance abuse treatment providers; and

• the use of technology, e.g., toll-free telephone numbers, automated reporting systems, etc.

Examples of activities may include, but not be limited to:

• how interim services are made available to individuals awaiting admission to treatment;

• the mechanism(s) utilized by programs for maintaining contact with individuals awaiting admission to treatment; and

• technical assistance.

GOAL # 10. An agreement to improve the process in the State for referring individuals to the treatment modality that is most appropriate for the individual (See 42 U.S.C. 300x-28(a) and 45 C.F.R. 96.132(a)).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 11. An agreement to provide continuing education for the employees of facilities which provide prevention activities or treatment services (or both as the case may be) (See 42 U.S.C. 300x-28(b) and 45 C.F.R. 96.132(b)).

FY 20045 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 12. An agreement to coordinate prevention activities and treatment services with the provision of other appropriate services (See 42 U.S.C. 300x-28(c) and 45 C.F.R. 96.132(c)).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 13. An agreement to submit an assessment of the need for both treatment and prevention in the State for authorized activities, both by locality and by the State in general (See 42 U.S.C. 300x-29 and 45 C.F.R. 96.133).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 14. An agreement to ensure that no program funded through the block grant will use funds to provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs (See 42 U.S.C. 300x-31(a)(1)(F) and 45 C.F.R. 96.135(a)(6)).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

GOAL # 15. An agreement to assess and improve, through independent peer review, the quality and appropriateness of treatment services delivered by providers that receive funds from the block grant (See 42 U.S.C. 300x-53(a) and 45 C.F.R. 96.136).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 20087 (Intended Use):

Attachment H: Independent Peer Review (See 45 C.F.R. 96.122(f)(3)(v))

For the fiscal year two years prior (FY 2005) to the fiscal year for which the State is applying for funds:

In up to three pages provide a description of the State’s procedures and activities undertaken to comply with the requirement to conduct independent peer review during FY 20064 (See 42 U.S.C. 300x-53(a)(1) and 45 C.F.R. 96.136).

Examples of procedures may include, but not be limited to:

• the role of the Ssingle State Aauthority (SSA) for substance abuse prevention activities and treatment services in the development of operational procedures implementing independent peer review;

• the role of the State Medical Director for Substance Abuse Services in the development of such procedures;

• the role of the independent peer reviewers; and

• the role of the entity(ies) reviewed.

Examples of activities may include, but not be limited to:

• the number of entities reviewed during the applicable fiscal year;

• technical assistance made available to the entity(ies) reviewed; and

• technical assistance made available to the reviewers, if applicable.

GOAL # 16. An agreement to ensure that the State has in effect a system to protect patient records from inappropriate disclosure (See 42 U.S.C. 300x-53(b), 45 C.F.R. 96.132(e), and 42 C.F.R. Ppart 2).

FY 20054 (Compliance):

FY 20076 (Progress):

FY 2008 7(Intended Use):

GOAL #17. An agreement to ensure that the State has in effect a system to comply with 42 U.S.C. 300x-65 and 42 C.F.R. part 54 (See 42 C.F.R. 54.8(b)(c)(4) and 54.8(c)(4)(b), Charitable Choice Provisions and Regulations).

FY 20054 (Compliance): Not Applicable

FY 20076 (Progress):

FY 20087 (Intended Use):

Under Charitable Choice, States, local governments, and religious organizations, each as SAMHSA grant recipients, must: (1) ensure that religious organizations that are providers provide notice of their right to alternative services to all potential and actual program beneficiaries (services recipients); (2) ensure that religious organizations that are providers refer program beneficiaries to alternative services; and (3) fund and/or provide alternative services. The term “alternative services” means services determined by the State to be accessible and comparable and provided within a reasonable period of time from another substance abuse provider (“alternative provider”) to which the program beneficiary (“services recipient”) has no religious objection.

The purpose of Attachment I is to document how your State is complying with these provisions.

Attachment I: Charitable Choice

For the fiscal year prior (FY 20076) to the fiscal year for which the State is applying for funds provide a description of the State’s procedures and activities undertaken to comply with the provisions.

Notice to Program Beneficiaries – Check all that apply:

 Used model notice provided in final regulations.

• Used notice developed by State (attached copy).

• State has disseminated notice to religious organizations that are providers.

• State requires these religious organizations to give notice to all potential beneficiaries.

Referrals to Alternative Services – Check all that apply:

• State has developed specific referral system for this requirement.

• State has incorporated this requirement into existing referral system(s).

 SAMHSA’s Treatment Facility Locator is used to help identify providers.

 Other networks and information systems are used to help identify providers.

 State maintains record of referrals made by religious organizations that are providers.

 Enter total number of referrals necessitated by religious objection to other

substance abuse providers (“alternative providers”), as defined above, made in

previous fiscal year. Provide total only; no information on specific referrals

required.

Brief description (one paragraph) of any training for local governments and faith-based and community organizations on these requirements.

Attachment J: Waivers

If your State plans to apply for any of the following waivers, check the appropriate box and submit the request for a waiver at the earliest possible date.

 To expend not less than an amount equal to the amount expended by the State for FY 1994 to establish new programs or expand the capacity of existing programs to make available treatment services designed for pregnant women and women with dependent children (See 42 U.S.C. 300x-22(b)(2) and 45 C.F.R. 96.124(d)).

 Rural area early intervention services HIV requirements

(See 42 U.S.C. 300x-24(b)(5)(B) and 45 C.F.R. 96.128(d))

 Improvement of process for appropriate referrals for treatment, continuing education, or coordination of various activities and services

(See 42 U.S.C. 300x-28(d) and 45 C.F.R. 96.132(d))

 Statewide maintenance of effort (MOE) expenditure levels

(See 42 U.S.C. 300x-30(c) and 45 C.F.R. 96.134(b))

 Construction/rehabilitation

(See 42 U.S.C. 300x-31(c) and 45 C.F.R. 96.135(d))

If your State proposes to request a waiver at this time for one or more of the above provisions, include the waiver request as an attachment to the application, if possible. The Interim Final Rule, 45 C.F.R. 96.124(d), 96.128(d), 96.132(d), 96.134(b), and 96.135(d), contains information regarding the criteria for each waiver, respectively. A formal waiver request must be submitted to SAMHSA at some point in time if not included as an attachment to the application.

Description of Calculations

In a brief narrative, provide a description of the amounts and methods used to calculate the following: (a) the base for services to pregnant women and women with dependent children as required by 42 U.S.C. 300x-22(b)(1); and, for 1994 and subsequent fiscal years report the Federal and State expenditures for such services; (b) the base and Maintenance of Effort (MOE) for tuberculosis services as required by 42 U.S.C. 300x-24(d); and, (c) for designated States, the base and MOE for HIV early intervention services as required by 42 U.S.C. 300x-24(d) (See 45 C.F.R. 96.122(f)(5)(ii)(A)(B)(C)).

Preparing to complete the Substance Abuse State Agency Spending Report (Form 4)

This form requires you to enter amounts of funds, by source, for each kind of activity. You will enter only funds flowing through the principal agency of the State that administered the SAPT Block Grant. Amounts must be entered in whole dollar amounts. Before you begin completing the form, do the following:

• Enter the State’s name in the box at the upper left.

• Enter in the box at the upper right the dates of the State expenditure period you identified on the Face Page (Form 1).

• Read the instructions carefully.

• Study the definitions of the row and column headings.

How to complete Form 4

First review the definitions of the activities listed at the left. Then make sure you understand which fund sources are entered in column A and which ones are entered in columns B through F.

Rows 1 through 5 – Activities

Rows 1 through 5 describe typical activities funded by the agency administering the SAPT Block Grant.

 Note: Do not include expenditures for primary prevention in Row 1.

Row 1: Block Grant Funds for Substance Abuse Prevention (other than primary prevention) and Treatment Servicesand Rehabilitation – Enter the amount of funds from the FY 2005 award for this purpose. This includes funds used for alcohol and drug prevention (other than primary prevention) and treatment activities. This also includes direct services to patients, such as outreach, detoxification, methadone detoxification and maintenance, outpatient counseling, residential rehabilitation including therapeutic community stays, hospital-based care, vocational counseling, case management, central intake, and program administration. Early intervention activities and treatment (other than primary prevention), substance abuse treatment and rehabilitation activities should be included as part of row 1. Do not include funds for administration cost in this row.

Row 2: Primary Prevention – This row collects information on primary prevention activities funded under the FY 20054 SAPT Block Grant. Primary prevention includes activities directed at individuals who do not require treatment for substance abuse. Such activities may include education, mentoringcounseling, and other activities designed to reduce the risk of substance abuse by individuals. Note that under the SAPT Block Grant statute, early intervention activities should not be included as part of primary prevention.

Row 3: Tuberculosis Services – This row collects information on tuberculosis services made available to individuals receiving treatment for substance abuse. Tuberculosis services include counseling, testing, and treatment for the disease. Funds made available from the grant to provide such services, either directly or through arrangements with other public or nonprofit private entities, should be recorded on row 3, column A.

Row 4: HIV Early Intervention Services – This row collects information on 1 or more projects established to make available early intervention services for HIV disease at the sites in which individuals are receiving treatment for substance abuse. Funds made available from the grant

> 2 percent < 5 percent, to establish such projects should be recorded on row 4, column A. This row is applicable to those “designated States” whose rate of cases of acquired immune deficiency syndrome is equal to or greater than the case rate specified in the statute (see 42 U.S.C. 300x-24(b) and 45 C.F.R. 96.128). The case rate data, as indicated by the number of such cases reported to and confirmed by the Director of the Centers for Disease Control and Prevention for the most recent calendar year for which such data are available,² refers to such data that is available on or before October 1 of the fiscal year for which the State is applying for a grant.

Row 5: Administration – This includes grants and contracts management, policy and auditing, personnel management, legislative liaison, and other overhead costs in large departments and agencies. For FY 20054, a maximum of 5 percent of the SAPT Block Grant may have been spent on administration at the State level.

Do not account for administration at the program (or service provider) level on this row. Program level administration expenditures should be accounted for in Rows 1 - 4 above, as appropriate.

Row 6: Column Total – Use this row to enter the total of Rows 1 through 5. The column A total amount should equal the amount of and may not exceed the FY 20054 SAPT Block Grant that appears on line 8 of the Notice of Block Grant Award (NGA).

Column A – Expenditures of SAPT Block Grant

Use this column to record your State’s use of FY 20054 SAPT Block Grant awards. In column A, enter FY 20054 block grant funds that were spent on each activity. Remember to enter amounts in whole dollar amounts.

Columns B through F – Expenditures of other funds

Use these columns to report on funds from other sources spent by the designated substance abuse agency during the 12-month expenditure period you entered in the box. Thus, the time period on which you report here is different from the one covered by column A. Here are the definitions for each column:

Column B: Medicaid – Enter the total of all Federal, State and local match Medicaid funds in this column.

Column C: Other Federal funds – This includes all other Federal funds for substance abuse that flow through the principal agency. Examples are HHS or other Federal categorical grant funds, Medicare, other public welfare funds such as Food Stamps (Title VIII), other public third party funds such as CHAMPUS, the Social Services Block Grant (Title XX), and the Maternal and Child Health Block Grant (Title V). Do not include Federal funds that go through other State offices/agencies or directly to providers.

Column D: State funds – This includes all State general funds or special appropriations administered by the principal agency, such as fines, fees, and earmarked taxes. This column provides an estimate of annual State funding.

Column E: Local funds – This includes appropriations from local government entities such as cities, other municipalities, special tax districts, and counties. Remember that local Medicaid match funds were reported in column B. Do not report them again here.

Column F: Other funds – This includes funds from all other sources such as patient fees, nonprofit private entities like the United Way and the Robert Wood Johnson Foundation, and private third party payers such as Blue Cross/Blue Shield, health maintenance organizations, and other commercial insurers. If your agency receives no local or other funds, enter zeroes in columns E and F.

Substance Abuse State Agency Spending Report (Include ONLY funds flowing through your agency.)
State:			Dates of State expenditure period: from ____________ to ____________ (Same as Form 1)
	Source of Funds
Activity (See instructions for using Row 1)	A. SAPT Block Grant		B. Medicaid (Federal, State, and Local)	C. Other Federal funds (e.g., Medicare, other public welfare)	D. State funds	E. Local funds (Excluding local Medicaid)	F. Other
	FY 20054 Award (spent)
1. Substance Abuse Prevention * and Treatment and Rehabilitation
2. Primary Prevention
3. Tuberculosis Services
4. HIV Early Intervention Services
5. Administration (excluding program/provider level)
6. Column Total

* Prevention other than Primary Prevention

Forms 4a and 4b: Detailing expenditures on primary prevention (Form 4, Row 2)

There are six primary prevention strategies typically funded by principal agencies administering the SAPT Block Grant. Here are the definitions of those strategies. If a State employs strategies not covered by these six categories, please report them under “Other” in a separate row for each one in Form 11a, or the State may choose to report activities utilizing the IOM Model of Universal Selective and Indicated in Form 11b. If a State chooses to complete Form 11b , Form 11a, Section 1926 – Tobacco row must be completed. PLEASE NOTE: CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

Primary Prevention Expenditures Checklist

Information Dissemination – This strategy provides knowledge and increases awareness of the nature and extent of alcohol and other drug use, abuse, and addiction, as well as their effects on individuals, families, and communities. It also provides knowledge and increases awareness of available prevention and treatment programs and services. It is characterized by one-way communication from the source to the audience, with limited contact between the two.

Education – This strategy builds skills through structured learning processes. Critical life and social skills include decision making, peer resistance, coping with stress, problem solving, interpersonal communication, and systematic and judgmental abilities. There is more interaction between facilitators and participants than in the information strategy.

Alternatives – This strategy provides participation in activities that exclude alcohol and other drugs. The purpose is to meet the needs filled by alcohol and other drugs with healthy activities, and to discourage the use of alcohol and drugs through these activities.

Problem Identification and Referral – This strategy aims at identification of those who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted however, that this strategy does not include any activity designed to determine if a person is in need of treatment.

Community-based Process – This strategy provides ongoing networking activities and technical assistance to community groups or agencies. It encompasses neighborhood-based, grassroots empowerment models using action planning and collaborative systems planning.

Environmental – This strategy establishes or changes written and unwritten community standards, codes, and attitudes, thereby influencing alcohol and other drug use by the general population.

Other – The six primary prevention strategies have been designed to encompass nearly all of the prevention activities. However, in the unusual case an activity does not fit one of the six strategies it may be classified in the “Other” category.

Section 1926 – Tobacco: Costs Associated with the Synar Program. Per Jan. 19, 1996, 45 CFR Part 96, Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants; Final Rule, States may not use the Block Grant to fund the enforcement of their statute, except that they may expend funds from their primary prevention set aside of their Block Grant allotment under 45 CFR 96.124(b)(1) for carrying out the administrative aspects of the requirements such as the development of the sample design and the conducting of the inspections.

States should include any non-SAPT funds that were allotted for Synar activities in the appropriate columns.

Costs Associated with the Development and Conduct of Random, Unannounced Tobacco Inspections – Include aggregate costs associated with carrying out the administrative aspects of the requirements such as the development of the sample design and the conducting of the inspections.

In addition, prevention strategies may be classified using the IOM Model of Universal, Selective and Indicated. Here are the definitions of those strategies. PLEASE NOTE: CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

Primary Prevention Expenditures Checklist

Institute of Medicine Classification: Universal Selective and Indicated:

• Universal: Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

  • Universal Direct interventions directly serve participants who have not been identified on the basis of individual risk.

  • Universal Indirect interventions support population-based activities and the provision of information and technical assistance.

• Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels. (Adapted from The Institute of Medicine Model of Prevention)

Now rRefer back to Form 4 and look at all the entries you made on row 2 primary prevention. Use the table below to indicate how much funding supported each of the six strategies on Form 4a or how much funding supported each of the IOM classifications, Universal, Selective or Indicated on Form 4b. Use the table below to indicate how much funding supported each of the six strategies. Enter in whole dollar amounts. For sources of funds other than the SAPT Block Grant, report only those funds made available during the expenditure period identified on

Form 4.

Form 4a. Primary Prevention Expenditures Checklist

	Block Grant FY 20054	Other Federal	State	Local	Other
Information Dissemination	$	$	$	$	$
Education	$	$	$	$	$
Alternatives	$	$	$	$	$
Problem Identification & Referral	$	$	$	$	$
Community-based process	$	$	$	$	$
Environmental	$	$	$	$	$
Other	$	$	$	$	$
Section 1926 - Tobacco	$	$ *	$ *	$ *	$ *
TOTAL	$	$	$	$	$

*Please list all sources, if possible (e.g., Center for Disease Control and Prevention block grant, foundations).

Form 4b. Primary Prevention Expenditures Checklist

	Block Grant FY 2005	Other Federal	State	Local	Other
Universal Indirect	$	$	$	$	$
Universal Direct	$	$	$	$	$
Selective	$	$	$	$	$
Indicated	$	$	$	$	$
TOTAL	$	$	$	$	$

*Please list all sources, if possible (e.g., Center for Disease Control and Prevention block grant, foundations).

Form 4c Resource Development Expenditure Checklist: How to report expenditures on substance abuse resource development activities

Expenditures on resource development activities may involve the time of State or sub-State personnel, or other State or sub-State resources. These activities may also be funded through contracts, grants, or agreements with other entities. Look at the following definitions to see if your State made these kinds of expenditures with the FY 20054 block grant award (column A on Form 4). Your State may use different terminology or a different classification system to describe these kinds of activities. Just do the best you can in converting your terminology into these seven categories.

Planning, coordination, and needs assessment – This includes State, regional, and local personnel salaries prorated for time spent in planning meetings, data collection, analysis, writing, and travel. It also includes operating costs such as printing, advertising, and conducting meetings. Any contracts with community-based organizations or local governments for planning and coordination fall into this category, as do needs assessment projects to identify the scope and magnitude of the problem, resources available, gaps in services, and strategies to close those gaps.

Quality assurance – This includes activities to assure conformity to acceptable professional standards and to identify problems that need to be remedied. These activities may occur at the State, sub-State, or program level. Sub-State administrative agency contracts to monitor service providers fall in this category, as do independent peer review activities.

Training (post-employment) – This includes staff development and continuing education for personnel employed in local programs as well as support and coordination agencies, as long as the training relates to substance abuse services delivery. Typical costs include course fees, tuition and expense reimbursements to employees, trainer(s) and support staff salaries, and certification expenditures.

Education (pre-employment) – This includes support for students and fellows in vocational, undergraduate, graduate, or postgraduate programs who have not yet begun working in substance abuse programs. Costs might include scholarship and fellowship stipends, instructor(s) and support staff salaries, and operating expenses.

Program development – This includes consultation, technical assistance, and materials support to local providers and planning groups. Generally these activities are carried out by State and sub-State level agencies.

Research and evaluation – This includes program performance measurement, evaluation, and research, such as clinical trials and demonstration projects to test feasibility and effectiveness of a new approach. These activities may have been carried out by the principal agency of the State or an independent contractor.

Information systems – This includes collecting and analyzing treatment and prevention data to monitor performance and outcomes. These activities might be carried out by the principal agency of the State or an independent contractor.

Form 4cb. Resource Development Expenditure Checklist

Now complete the following checklist:

Did your State fund resource development activities from the FY 20054 block grant?

 Yes  No

If yes, show the actual or estimated amounts spent. These amounts may be part of the SAPT Block Grant funds shown on Form 4 in Column A under lines 1 through 5: (1) Substance Abuse Prevention (other than primary prevention) and Treatment and Rehabilitation, (2) Primary Prevention, (3) Tuberculosis Services, (4) HIV Early Intervention Services, and (5) Administration (excluding program/provider level). Note that in describing resource expenditures, you are not limited to line 5 (Administration) funds alone.

List your expenditures in the following three columns: (1) Treatment, showing amounts spent for treatment resource development; (2) Prevention, showing amounts spent for primary prevention resource development; and (3) Additional Combined Expenditures, showing amounts for resource development in situations where you cannot separate out the amounts devoted specifically to treatment or prevention. For column 3, do not include any amounts listed in columns 1 and 2.

Column 4, Total, shows the sum of all expenditures listed on that line in columns 1, 2, and 3. Enter amounts in whole dollars.

Column 1 Column 2 Column 3

Additional

Treatment Prevention Combined Total

 Planning, coordination, $ $ $ $________

and needs assessment

 Quality assurance $ $ $ $________

 Training (post-employment) $ $ $ $________

 Education (pre-employment) $ $ $ $________

 Program development $ $ $ $________

 Research and evaluation $ $ $ $________

 Information systems $ $ $ $________

TOTAL $ $ $ $

Please indicate whether expenditures on resource development activities are actual or estimated.

 Actual  Estimated

3. Substance Abuse Entity Inventory (Form 6)

This item documents the activities for which FY 20054 funds were expended by entity. This information is required by CSAT to meet its obligations under the Federal Managers Financial Integrity Act of 1982 (See 31 U.S.C. 3512). The item requires completion of the Substance Abuse Entity Inventory followed by a listing of entities without an Inventory of Substance Abuse Treatment Services (I-SATS) ID that received funds from the FY 20054 SAPT Block Grant to provide substance abuse prevention and treatment services.

The term “entities” is used to cover State and non-State providers, sub-recipient agencies and contractors, grantees, and other programs or entities directly funded by the State. It includes all direct providers of substance abuse prevention activities and treatment services. Expenditures, including grants and contracts of $25,000 or less for similar purposes and similar areas, may be aggregated into a single line in column 1 if these funds are used by the same State ID/I-SATS ID number. Include only those entities that receive block grant funds.

Form 6 combines a great deal of important information. It identifies how and where each entity used FY 20054 block grant funds and State Funds provided through the Single State Agency and how much of the funding went to substance abuse prevention and treatment services (other than primary prevention), primary prevention activities, services for HIV early intervention and services for pregnant women and women with dependent children.

Preparing to complete Form 6

Make a list of all entities that received FY 20054 block grant funds and/or State funds in the period covered in Column D, Form 4 and/or to which FY 20054 block grant funds have been obligated. Each entity must have a unique number. You can either number the list consecutively, starting with 1, or use unique State identifier numbers. It does not matter which entity goes first on the list. If an entity has an Inventory of Substance Abuse Treatment Services (I-SATS) ID, place that ID number after the name. If your State funded direct service providers have not yet been assigned a number, call the contractor for the Office of Applied Studies, SAMHSA, Ms. Tara Jones at 703-807-2351 or contact her by e-mail at [email protected] , to obtain one or complete the list attached to Form 6 (described immediately before Form 6aA). If you are not using Web-BGAS, you will need multiple copies of the form. Enter the State’s name on each copy.

How to complete Form 6

(Please note this form has changed to remove unnecessary columns and to simplify the format.) This form should be filled out in two stages. The first stage involves completion of columns 1 through 3. These columns record information about the entity. The second stage involves completion of columns 4 through 7. These columns record information about the use of funds.

Detailed instructions for each stage follow on the next page.

Stage one: Entering entity information (Columns 1 through 3)

First complete columns 1 through 3 for each entity on your list, starting with the first one.

Column 1: Entity number – This is the number from the entity list you assembled in preparing to complete the form.

Column 2: I-SATS ID – If the entity has an I-SATS ID, enter that number here. Place an “X” in the box if the entity has no I-SATS ID.

Column 3: Area served – This column shows the geographical area served by the entity and involves coded entries. Enter the code you assigned for the sub-State area(s) that the entity serves. Each State may elect how to define its sub-State planning areas. Please append a definition of each sub-State planning area by geographic entity. As an example, if sub-State planning area A comprises four counties, list the county names; if sub-State planning area A is a major metropolitan area and sub-State planning area B comprises the surrounding counties, provide that information. States are encouraged to keep the number of areas to a minimum; however, States must identify at least two sub-State planning areas. These same areas will be used in the needs assessment required in Section III of this application.

• An entity may serve the whole State (Statewide) or an entity may serve several areas. For example, entity 1 is a program that serves the entire State. When completing column 3 for this entity, enter a code of ‘99.’

• When using the electronic Web Block Grant Application System (Web BGAS), a code of ‘99’ must be entered for any ‘Statewide’ program. No other code will be accepted by the program.

When an entity serves more than one sub-State Planning Areas(s) (SPAs), you will use multiple lines. For example, entity 2 serves two of the SPAs your State designates. You must complete columns 1-3 in one row for the first SPA the entity serves. You must then complete columns 1-3 of a second row for the second SPA the entity serves.

Stage two: Entering funding information (Columns 4 through 7)

These columns describe funding to providers and other entities and how the funding was used for substance abuse prevention activities and treatment services. They require distributing the funding in various ways. Remember that you have to fill out all these columns for every line you completed in stage one. If a column is not applicable to a given line, put a zero in that column. All of the columns, with the exception of column 4, refer to SAPT Block Grant funding only.

Column 4: State funds – Include all State funds spent during the 12-month State expenditure period you designated on Form 4. These funds were reported in column D on Form 4.

• Columns 5 through 7 refer only to the portion of the FY 20054 block grant award that went to either direct or indirect service providers, i.e., entities. Do not include funds spent on State staff or administration.

Column 5: SAPT Block Grant funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services –Enter the amount of funds from the FY 20054 award for this purpose. This includes funds used for alcohol and drug prevention (other than primary prevention) and treatment activities. This also includes direct services to patients, such as outreach, detoxification, methadone detoxification and maintenance, outpatient counseling, residential rehabilitation including therapeutic community stays, hospital-based care, vocational counseling, case management, central intake, and program administration. Early intervention activities and treatment (other than primary prevention), substance abuse treatment and rehabilitation activities should be included as part of column 5. Do not include funds for administration cost in this column.

Column 5a: SAPT Block Grant funds for Pregnant Women and Women with Dependent Children - Enter the amount of funds from the FY 20054 award for this purpose. This includes treatment for pregnant women and women with dependent children, and women in treatment for prenatal care and childcare. Tuberculosis expenditures are not to be included in the expenditure reports for pregnant women and women with dependent children. Do not include funds for administration costs in this column.

Column 5a is a subset of the expenditures reported in column 5. For example, a provider may operate an alcohol treatment program targeted toward women. The FY 20054 block grant funding for this provider would be entered twice, first in column 5 and again in column 5a.

Column 6: SAPT Block Grant funds for primary prevention – Enter the amount of funds from the FY 20054 award for this purpose. This includes funds for education and counseling, and for activities designed to reduce the risk of substance abuse. Do not include funds for administration cost in this column.

Column 7: SAPT Block Grant funds for HIV Early Intervention Services – Enter the amount of funds from the FY 20054 award for this purpose, if applicable. Include funds for pre-test counseling, testing, post-test counseling, and the provision of therapeutic measures to diagnose the extent of deficiency in the immune system to prevent and treat the deterioration of immune system, and to prevent and treat conditions arising from the disease. Include the cost of making referrals to other treatment providers in this item. Do not include funds for administration cost in this column.

Provider Address List to be attached to Form 6

Immediately following the Substance Abuse Entity Inventory form, insert a list of each entity that does not have a I-SATS ID number and provide the entity’s name, street address, city/state (including zip code), and telephone number (including area code). Use the same unique identifying number that you provided on Form 6 in column 1. (If your State is submitting an electronic application, enter this list as records in the screens immediately following Form 6.)

							Page _____ of _____ pages
SUBSTANCE ABUSE ENTITY INVENTORY (Complete columns 1-3 first. Then complete columns 4-7 for each entry.)
State:				FISCAL YEAR 20054
1. Entity Number	2. National Register (I-SATS) ID Mark [X] box if no ID	3. Area Served 99-Statewide or Enter Sub-State Area Code (Enter only one SPA Per Line)	4. State Funds (Spent during State Expenditure Period.)	5. SAPT Block Grant Funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services	5.a. SAPT Block Grant Funds for Services for Pregnant Women and Women with Dependent Children	6. SAPT Block Grant Funds for Primary Prevention.		7. SAPT Block Grant Funds for Early Intervention Services for HIV (If Applicable)
	[ ]
	[ ]
	[ ]
	[ ]
	[ ]

Prevention Strategy Rreport (Form 6aA)

NOTE: Completion of portions of this form will be optional for a further three years except for column B, which will be required until the phase in year 2010. During this time, SAMHSA would like to continue to work with the States to refine and finalize this form. SAMHSA is especially interested in developing common definitions for the elements being reported and identifying data sources which may be used to provide these data. States are requested to complete the form as completely as possible (e.g., at least column B and as much more as possible). Provide any comments that will enhance the meaningfulness of the information and aid in improving the completeness, validity and reliability of the data.

The Prevention Strategy Report requires additional information (in accordance with sSection 1929 of the PHS Act) about the primary prevention activities conducted by the entities listed on Form 6, column 6. It seeks further information on the specific strategies and activities being funded by the principal agency of the State that addresses the sub-populations at risk for alcohol, tobacco, and other drug (ATOD) use/abuse.

Instructions for completing Form 6aA

This form has three columns. The first column seeks information about the sub-populations at risk that are being addressed by the State’s primary prevention program; the second column seeks information about the specific primary prevention strategy(ies) and activities being employed to address each of these risk categories; and the third column seeks information about the total number of providers carrying out each of the activities reported in column B. States are required only to complete column B each year and are strongly encouraged to complete the other 2 columns, where possible. If the State completes optional column A, it need only report on those risk categories that were considered appropriate for its primary prevention program and that were addressed during the reporting year. In completing Column B, the State need only report on those strategies and activities that were considered appropriate and that were conducted during the reporting year.

Column A: Risk categories

States are asked to list each of the sub-populations at risk toward which their primary prevention program is directed. One risk category should be listed on each line. The risk categories and codes are listed below. (SAMHSA recognizes that resource limitations may result in a State’s addressing only those risk categories of greatest concern.) For any risk category not listed below, code the category using codes beginning with “11” and enter a description on the same line. For example, if your State uses three risk categories that do not fit into any of the categories below, enter the code “11” and description of the category. The second category would be coded as “12” and its description beside it. The third category would be coded as “13,”, etc.

01 Children of substance abusers

02 Pregnant women/teens

03 Drop-outs

04 Violent and delinquent behavior

05 Mental health problems

06 Economically disadvantaged

07 Physically disabled

08 Abuse victims

09 Already using substances

10 Homeless and/or runaway youth

11 Other, specify

Column B: Strategy/activity

This column describes the primary prevention strategy/activity or strategies and activities used by the principal agency of the State to address each of the risk categories identified in column A and involves coded entries listed below. The definitions for these strategies have been provided in the block grant regulations and are repeated in Section III of this Application. If a State employs strategies not covered by these six categories, please report these under “Other Strategies.”

A State may employ several strategies and activities for each risk category. For example, it may provide both parenting classes and a clearinghouse. Each strategy used to address a risk category should be listed on a separate line.

If you code “Other, specify,” enter the description of the type of strategy/activity on the same line.

The codes for use in column B are:

Information Dissemination

01 Clearinghouse/information resources centers

02 Resource directories

03 Media campaigns

04 Brochures

05 Radio and TV public service announcements

06 Speaking engagements

07 Health fairs and other health promotion, e.g., conferences, meetings, seminars

08 Information lines/Hot lines

09 Other, specify

Education

11 Parenting and family management

12 Ongoing classroom and/or small group sessions

13 Peer leader/helper programs

14 Education programs for youth groups

15 Mentors

16 Preschool ATOD prevention programs

17 Other, specify

Alternatives

21 Drug free dances and parties

22 Youth/adult leadership activities

23 Community drop-in centers

24 Community service activities

25 Outward Bound

26 Recreation activities

27 Other, specify

Problem Identification and Referral

31 Employee Assistance Programs

32 Student Assistance Programs

33 Driving while under the influence/driving while intoxicated education programs

34 Other, specify

Community-Based Process

41 Community and volunteer training, e.g., neighborhood action training, impactor training, staff/officials training

42 Systematic planning

43 Multi-agency coordination and collaboration/coalition

44 Community team-building

45 Accessing services and funding

46 Other, specify

Environmental

51 Promoting the establishment or review of alcohol, tobacco, and drug use policies in schools

52 Guidance and technical assistance on monitoring enforcement governing availability and distribution of alcohol, tobacco, and other drugs

53 Modifying alcohol and tobacco advertising practices

54 Product pricing strategies

55 Other, specify

Other prevention activities

For any prevention activity not included in the list above, code the activity using codes beginning with “71” and enter a description on the same line. For example, if your State uses three unique primary prevention activities that do not fit into any of the categories above, enter the code “71” in column B and description of the activity. The second activity would be coded as “72” and its description would be entered on a separate line. The third strategy would be coded as “73,” etc.

Column C: Providers

This column records the number of providers performing each of the activities identified in Column B. Providers are those entities reported on Form 6 of the application as having expended primary prevention set-aside funds.

Enter the total number of providers that employ a specific strategy/activity to address the prevention needs of a risk category before proceeding to the next line.

Prevention Strategy Report Risk-Strategies
State:
Column A (Risks)		Column B (Strategies)	Column C (Providers)
Children of Substance Abusers [1]
Pregnant Women / Teens [2]
Drop-Outs [3]
Violent and Delinquent Behavior [4]
Mental Health Problems [5]
Economically Disadvantaged [6]
Physically Disabled [7]
Abuse Victims [8]
Already Using Substances [9]
Homeless and/or Runaway Youth [10]
Other, Specify [11]

4. How to complete Forms 7aA and 7bB

These items require the completion of the Treatment Utilization Matrix (Forms 7aA) and the matrix for Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services (Form 7bB).

These Forms are intended to capture the unduplicated count of persons with initial admissions to an episode of care (as defined in the Treatment Episode Data System standards) during the 12-month State expenditure period you designated on Form 1. Note that in Form 7aA, column B is a subset of column A. Numbers admitted seeks to capture information by level of care on the number of initial admissions to an episode of care during the 12-month State expenditure period you designated on Form 1. Clients served during the State Expenditure Period is a subset of Column A requiring the State to count individuals only once for each level of care even if they terminate and are readmitted to that level of care during the 12-month time period. A client is defined as an individual served even if the only service they receive is admission.

In Form 7bB, each client with an initial admission to any level of care during the State Expenditure Period is to be reported only once. Note that the Form 7aA rows are not to be totaled nor would that total be expected to equal the total of Form 7bB.

Form 7aA documents the levels and amounts of care purchased Statewide during the 12-month State expenditure period you designated on Form 1, by the principal agency of the State administering the block grant. Include all care purchased with public dollars, regardless of the source of funds.

How to Complete Form 7aA (Treatment Utilization Matrix)

The rows on Form 7aA define levels of care. The definitions are as follows:

DETOXIFICATION (24-HOUR CARE)

Row 1: Hospital inpatient – Twenty-four hour/day medical acute care services for detoxification for persons with severe medical complications associated with withdrawal.

Row 2: Free-standing residential – Twenty-four hour/day services in a non-hospital setting that provide for safe withdrawal and transition to ongoing treatment.

REHABILITATION/RESIDENTIAL

Row 3: Hospital inpatient - Twenty-four hour/day medical care (other than detoxification) in a hospital facility in conjunction with treatment services for alcohol and other drug abuse and dependency.

Row 4: Short-term (up to 30 days) – Short-term residential, typically 30 days or less of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency.

Row 5: Long-term (over 30 days) - Long-term residential, typically over 30 days of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency (may include transitional living arrangements such as halfway houses).

AMBULATORY (OUTPATIENT)

Row 6: Outpatient – Treatment/recovery/aftercare or rehabilitation services provided where the patient does not reside in a treatment facility. The patient receives drug abuse or alcoholism treatment services with or without medication, including counseling and supportive services. Day treatment is included in this category. This also is known as nonresidential services in the alcoholism field.

Row 7: Intensive outpatient – Services provided to a patient that last two or more hours per day for three or more days per week.

Row 8: Detoxification – Outpatient treatment services rendered in less than 24 hours that provide for safe withdrawal in an ambulatory setting (pharmacological or non-pharmacological).

Row 9: Opioid Replacement Therapy Methadone - Report the number of clients for whom it was planned to use opioid replacement therapy during their course of who received methadone services as a planned part of their treatment.

Reporting on Form 7aA Levels of Care (Treatment Utilization Matrix)

All numbers should reflect treatment services provided to clients with an initial admission to an episode of care during the 12-month State Expenditure Period that you designated on Form 1. Your State may not have funded all levels of care. If any row is not applicable, enter zeroes in the appropriate columns.

States must report treatment utilization data in columns A and B and are requested to report data in columns C, D, and E if possible.

Column A: Report the total number of initial admissions to an episode of care for each of the nine levels of care during the 12-month State Expenditure Period designated on Form 1. Each re-admission of a client that occurs during the applicable 12-month time frame would be counted.

Column B: Report the unduplicated number of persons served within the set of persons who were admitted during the 12-month period specified on Fform 1. Note that column B is a subset of column A. Clients served during the State Expenditure Period are counted only once in each applicable level of care, even if they terminate and are readmitted during the 12-month time period.

Column C: Report the mean cost per person served for each of the nine levels of care. The mean cost is the total cost, including operating and capital costs, divided by the number of persons served. If your program offers services to family members and others besides the client, then count only those persons who actually have a treatment record and have received counseling or treatment services. For example, children would not be counted if they receive only daycare within a women’s program that is providing treatment to their mother.

Column D: Report the median cost per person for each of the nine levels of care.

Column E: Report the standard deviation of cost per person for each of the nine levels of care.

Treatment Utilization Matrix
	Dates of State expenditure period from _______ to _______ (Same as Form 1)
STATE:			Costs per Person
LEVEL OF CARE	A. Number of Admissions	B. Number of Persons Served	C. Mean Cost of Services	D. Median Cost of Services	E. Standard Deviation of Cost
Detoxification (24-Hour Care)
1. Hospital Inpatient			$	$	$
2. Free-Standing Residential			$	$	$
Rehabilitation/Residential
3. Hospital Inpatient			$	$	$
4. Short-term (up to 30 days)			$	$	$
5. Long-term (over 30 days)			$	$	$
Ambulatory (Outpatient)
6. Outpatient			$	$	$
7. Intensive Outpatient			$	$	$
8. Detoxification			$	$	$
9. Opioid Replacement TherapyMethadone			$	$	$

Reporting on Form 7bB (Number of Persons Served [Unduplicated Count] for Alcohol and Other Drug Use in State-Funded Services)

In Form 7bB, each client initiating care during the State Expenditure Period is to be reported on this form according to age, sex, racial and ethnic categories. In addition, this form also documents the number of clients who were pregnant. A separate cell is also provided to capture data on clients served in this reporting period but admitted in a prior period.. These data aggregations by race and ethnicity are the categories required by the October 30, 1997 revision of OMB Statistical Policy Directive No. 15: Race and Ethnic Standards for Federal Statistics and Administrative Reporting (http://www.whitehouse.gov/omb/fedreg/ombdir15.html).

Form 7bB covers persons admitted and served through care purchased statewide by the principal agency of your State that administered the block grant during the 12-month State Expenditure Period you designated on Form 1. Include all care purchased with public dollars, regardless of the source of funds.

Column A: Report the total number of persons served statewide (unduplicated count) for each age group in rows 1 through 5, with the sum of persons in all age groups shown in row 6. Row 7 is the total number of these clients who were pregnant.

Columns B through H: Report the number of persons served (unduplicated count) for rows 1 through 5 across sex and race/ethnicity columns B through H. For the “total” row 6, enter the number of persons served for the total group captured within each column. The total of columns B through H should equal the total reported in Column A.

Columns I and J: Report the number of persons by sex and age who are either (I) not Hispanic or Latino or (J) Hispanic or Latino. Note that the total of Columns I and J should also equal the total reported in Column A. In row 7, the total number of pregnant clients in columns I and J, as well as the total number in columns B through H, should both equal the total in Column A.

• Did the values reported by your State on Forms 7aA and 7bB come from a client-based system(s) with unique client identifiers?

 Yes  No

In the second section of Form B, report the Numbers of Persons Served during this period who were admitted prior to the current 12 month reporting period but were not counted in the first section of Form 7bB.

Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services by Age, Sex, and Race/Ethnicity

State:

Sex and Race/Ethnicity

Age

A. TOTAL

B. WHITE

C. BLACK OR AFRICAN AMERICAN

D. NATIVE HAWAIIAN/ OTHER PACIFIC ISLANDER

E. ASIAN

F. AMERICAN INDIAN / ALASKA NATIVE

G. MORE THAN ONE RACE REPORTED

H. UNKNOWN

I. NOT HISPANIC OR LATINO

J. HISPANIC OR LATINO

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

1. 17 & Under

2. 18 - 24

3. 25 – 44

4. 45 – 64

5. 65 and over

6. Total

7.Pregnant Women

Numbers of Persons Served who were admitted in a Period Prior to the 12 month reporting Period

 

5. Maintenance of Effort (MOE) Tables: (Single State Agency (SSA) MOE, TB MOE, HIV MOE, and Women’s Base and Expenditures).

Description of Calculations

If revisions or changes are necessary to prior years’ description of the following, please provide: a brief narrative describing the amounts and methods used to calculate the following: (a) the base for services to pregnant women and women with dependent children as required by 42 U.S.C. 300x-22(b)(1); and, for 1994 and subsequent fiscal years report the Federal and State expenditures for such services; (b) the base and Maintenance of Effort (MOE) for tuberculosis services as required by 42 U.S.C. 300x-24(d); and, (c) for designated States, the base and MOE for HIV early intervention services as required by 42 U.S.C. 300x-24(d) (See 45 C.F.R. 96.122(f)(5)(ii)(A)(B)(C)).

Instructions and Forms for completing Tables I through IV

If the State uses BGAS, these forms are pre-populated with data reported in prior years. The State may request to remove this data by clicking the button on the relevant MOE form in Web-BGAS.

Table I

Table I is a Maintenance of Effort (MOE) table tracking substance abuse funds flowing through the SSA during each State fiscal year (SFY). See (42 USC 300x-30 and 45 CFR 96.134).

• Enter expenditures for SFYs 20054, 20065, and 20076 in the corresponding boxes (B1, B2 and B3) in column B. (The State may, with approval from the Secretary, exclude from the calculation non-recurring expenditures awarded to the SSA for a specific purpose for SFY 2001 and subsequent fiscal years, see below).

• Compute the average of the amounts in B1 and B2 by adding the two amounts and dividing by 2. Enter the resulting average in Box C2.

The MOE for State fiscal year (SFY) 20076 is met if the amount in Box B3 is greater than or equal to the amount in Box C2 assuming the State complied with MOE requirements in these previous years.

The State may request an exclusion of certain non-recurring expenditures for a singular purpose from the calculation of the MOE, provided it meets SAMHSACSAT approval based on review of the following information:

Did the State have any non-recurring expenditures for a specific purpose which were not included in the MOE calculation?

Yes____ No ___

If yes, specify the amount and the State fiscal year ___________.

Did the State include these funds in previous year MOE calculations? Yes___ No___.

When did the State submit a request to the SAMHSA Administrator to exclude these funds from the MOE calculations? (Date) / /

Table I

Total Single State Agency (SSA) Expenditures for Substance Abuse

Period (A)	Expenditures (B)	B1 (20054) + B2 (20065) 2 (C)
SFY 20054 (1)
SFY 20065 (2)
SFY 20076 (3)

Are the expenditure amounts reported in Columns B “actual” expenditures for the State fiscal years involved?

FY 20054 Yes No

FY 20065 Yes No

FY 20076 Yes No

If estimated expenditures are provided, please indicate when “actual” expenditure data will be submitted to SAMHSA: mm/dd/yyyy

Table II

Table II is a MOE table tracking all Statewide, non-Federal funds spent on Tuberculosis (TB) services to substance abusers in treatment during each SFY.

1. Enter State funds spent on TB services for SFY 1991 in box A1 of Table II (Base).

2. Enter the actual or estimated percent of these funds that was spent on substance abusers in treatment for SFY 1991 in box B1 of Table II (Base).

3. Divide this percent by 100 to change it to a decimal.

4. Multiply the amount in box A1 by the decimal value of the amount in box B1. Enter the resulting amount in box C1 of Table II (Base).

5. Follow the same procedure for row 2 in Table II (Base) as was done in row 1.

6. Compute the average of the amounts in boxes C1 and C2. Enter the resulting average (MOE Base) in box D2.

7. Follow the above procedure (steps 1 through 4) for rows 3 and 4 of Table II (Maintenance).

The TB MOE is met in State fiscal year 20076, if the amount in box C3 is equal to or greater than the amount in box D2 of the top chart.

Table II (BASE)

Statewide Non-Federal Expenditures for Tuberculosis Services to Substance Abusers in Treatment

Period	Total of All State Funds Spent on TB Services (A)	% of TB Expenditures Spent on Clients who were Substance Abusers in Treatment (B)	Total State Funds Spent on Clients who were Substance Abusers in Treatment (AxB) (C)	Average of Column C1 and C2 C1 + C2 2 (MOE BASE) (D)
SFY 1991 (1)
SFY 1992 (2)

Table II (MAINTENANCE)

Statewide Non-Federal Expenditures for Tuberculosis Services to Substance Abusers in Treatment

Period	Total of All State Funds Spent on TB Services (A)	% of TB Expenditures Spent on Clients who were Substance Abusers in Treatment (B)	Total State Funds Spent on Clients who were Substance Abusers in Treatment (AxB) (C)
SFY 20076 (3)

Table III

Table III is an MOE table that tracks all non-Federal funds spent on early intervention services for HIV provided to substance abusers in treatment at the site at which they receive substance abuse treatment during each SFY. If you use Web-BGAS, Web-BGAS will provide you with the appropriately configured table. If you plan to use the MS Word version, you must complete the generic table using the instructions below.

COMPLETE TABLE III ONLY IF YOUR STATE WAS A DESIGNATED STATE

1. If you are a designated State, enter the most recent Federal fiscal year in which your State became a designated State.

2. Enter State funds spent on early intervention services for HIV during the two years prior to the year you have identified in response to Number 1 above in boxes A1 and A2 in the left chart.

3. Compute the average of the amounts in boxes A1 and A2. Enter the resulting average (MOE Base) in box B2.

4. Enter State funds spent on early intervention services for HIV for State fiscal year 20076 box A3 of the right chart (MAINTENANCE).

The HIV MOE is met in State fiscal year 20076, if the amount in box A3 in the right chart (MAINTENANCE), is equal to or greater than the amount in box B2 of the corresponding left chart (MOE Base).

Table III (BASE And MAINTENANCE)

Statewide Non-Federal Expenditures for HIV Early Intervention Services to Substance Abusers in Treatment (Table III)

Enter the year in which your State last became a designated State, FFY____. Enter the 2 prior years’ expenditure data in A1 and A2. Compute the average of the amounts in boxes A1 and A2. Enter the resulting average (MOE Base) in box B2.

(BASE) (MAINTENANCE)

Period	Total of All State Funds Spent on Early Intervention Services for HIV (A)	Average of Columns A1 and A2 A1+A2 2 (MOE Base) (B)		Period	Total of All State Funds Spent on Early Intervention Services for HIV (A)
SFY ____ (1)
SFY____ (2)				SFY 20076 (3)

Table IV

Table IV tracks the total (block grant and State) expenditures for services to substance using pregnant women and women with dependent children during each fiscal year.

1. For 1994, enter the base in column A.

2. For Federal fiscal year 1995 and subsequent fiscal years the States must maintain expenditures for services for pregnant women and women with dependent children at a level that is not less than the FY 1994 expenditures; however, the expenditures may be any combination of SAPT Block Grant and State general revenue (including the State’s contribution to Medicaid). Report expenditures for Federal Fiscal Years 20054, 20065, and 20076 expenditures in column B.

Table IV (MAINTENANCE)

Expenditures for Services to Pregnant Women

and Women with Dependent Children

Period	Total Women’s BASE (A)	Total Expenditures (B)
1994
20054
20065
20076
Enter the amount the State plans to expend in FY 20087 for services for pregnant women and women with dependent children (amount entered must be not less than amount entered in Table IV Maintenance - Box A (1994)): $ __________

SECTION III: STATE PLAN – INTENDED USE OF FY 20087

SUBSTANCE ABUSE PREVENTION AND TREATMENT

BLOCK GRANT FUNDS

This section describes how the State will use the FY 20087 SAPT Block Grant award. The following is an overview of its information requirements:

Item			What you need to submit
(See Section II for narratives of intended goals, objectives, activities)
1.	Planning	Narrative and checklist
2.	Needs assessment summary	Form 8 plus narrative
3.	Needs by age, sex, and race/ethnicity	Form 9 plus narrative
4.	Intended use plan	Form 11 and two checklists
5.	Treatment capacity	Form 12
6.	Purchasing services	Two Checklists
7.	Program performance monitoring	Checklist

1. Planning

This item addresses compliance of the State’s planning procedures with several statutory requirements. It requires completion of narratives and a checklist.

These are the statutory requirements:

• 42 U.S.C. 300x-29, 45 C.F. R. 96.133 and 45 C.F.R. 96.122(g)(13) requires the State to submit a Statewide assessment of need for

• both treatment and prevention.

• 42 U.S.C. 300x-51 requires the State to make the State plan public in such a

manner as to facilitate public comment from any person during the development

of the plan.

In a narrative of up to three pages, describe how your State carries out sub-State area planning and determines which areas have the highest incidence, prevalence, and greatest need. Include a definition of your State’s sub-State planning areas. Identify what data is collected, how it is collected, and how it is used in making these decisions. If there is a State, regional, or local advisory council, describe their composition and their role in the planning process. Describe the monitoring process the State will use to assure that funded programs serve communities with the highest prevalence and need. Those States that have ingIf there is a State Epidemiological Workgroup or a State Epidemiological Outcomes Workgroup, must describe its composition and its contribution roleto in needs assessment, planning, and evaluation processes for primary prevention and treatment planning. States are encouraged to utilize the epidemiological analyses and profiles to establish substance abuse prevention and treatment goals at the State level.

• 42 U.S.C. 300x-51 and 45 C.F. R. 96.23(a)(13) require the State to make the State plan public in such a manner as to facilitate public comment from any person during the development of the plan.

In a narrative of up to two pages, describe the process your State used to facilitate public comment in developing the State’s plan and its FY 20087 application for SAPT Block Grant funds.

Criteria for Allocating Funds

Use the following checklist to indicate the criteria your State will use in deciding how to allocate FY 20087 block grant funds. Mark all criteria that apply. Indicate the priority of the criteria by placing numbers in the boxes. For example, if the most important criterion is “incidence and prevalence levels,” put a “1” in the box beside that option. If two or more criteria are equal, assign them the same number.

 Population levels (Specify formula:_______________________________)

 Incidence and prevalence levels

 Problem levels as estimated by alcohol/drug-related crime statistics

 Problem levels as estimated by alcohol/drug-related health statistics

 Problem levels as estimated by social indicator data

 Problem levels as estimated by expert opinion

 Resource levels as determined by (specify method) .

 Size of gaps between resources (as measured by) and needs (as estimated by).

 Other (specify):

2. Needs assessment summary

These items involve completion of the Treatment Needs Assessment Summary Matrix (Form 8), the Needs by Age, Sex and Race/Ethnicity (Form 9), and a narrative explaining how the State arrived at the numbers entered on these forms, the biases of the data, and how the State intends to improve the reliability and validity of its data. This information is required by statute and regulation (See 42 U.S.C. 300x-29 and 45 C.F.R. 96.133).

How to complete the Treatment Needs Assessment Summary Matrix (Form 8)

Before you begin entering numbers, look at columns 6 and 7. It is the intent of Congress to target funding to areas severely impacted by substance use and trade. There are various ways to measure both the prevalence of substance-related criminal activity and the incidence of communicable diseases. With input from the States, CSAT has designated two indices for column 6 (Prevalence of substance-related criminal activity). These indices are:

• number of DWI (driving while intoxicated) arrests

• number of drug-related arrests

Before you begin to enter data, fill in the box over column 6 indicating the time period covered by the entries you will make in that column. The time period on which you report in this column is the last calendar year for which you have the data. In addition, you may use a third index of your choice for this column. If you choose to do so, write your index in the blank space in column 6C. If you choose not to enter a third index, cross out column 6C.

With input from the States, CSAT has designated three indices for column 7 (Incidence of communicable diseases). These indices are:

• number of cases of Hepatitis B per 100,000 population

• number of cases of AIDS per 100,000 population

• number of cases of Tuberculosis per 100,000 population

Before you begin to enter data, fill in the box over column 6 indicating the time period covered by the entries you will make in that column.

Following are instructions for completing each column:

Column 1: Sub-State planning area – Enter the name of each sub-State planning area.

Column 2: Total population – Enter the total population of the sub-State planning area.

Column 3: Total population in need – Enter on the left side (A) the area’s total population in need of substance abuse treatment services, including those already receiving treatment. Enter on the right side (B) those who would seek treatment but are not currently being served.

Column 4: Number of IVDUs in need – Enter on the left side (A) the area’s total number of IVDUs in need, including those in treatment. Enter on the right side (B) those who would seek treatment but are not currently being served.

Column 5: Number of women in need – Enter on the left side (A) the area’s total number of women in need of substance abuse services, including those in treatment. Enter on the right side (B) those who would seek it but are not currently being served.

Column 6: Prevalence of substance-related criminal activity – Using the indices provided and the one you may have selected and written in, enter the appropriate numbers.

Column 7: Incidence of communicable diseases – Using the indices provided, enter the appropriate numbers. Do not enter data as fractions. For example, if there are 40.2 cases per 100,000 population, write “40.2” rather than “40.2/100,000.”

How your State determined the estimates for Form 8 and Form 9

Under 42 U.S.C. 300x-29 and 45 C.F.R. 96.133, States are required to submit annually a needs assessment. This requirement is not contingent on the receipt of Federal needs assessment resources. States are required to use the best available data. Using up to three pages, explain what methods your State used to estimate the numbers of people in need of substance abuse treatment services, the biases of the data, and how the State intends to improve the reliability and validity of the data. Also indicate the sources and dates or timeframes for the data used in making these estimates reported in both Forms 8 and 9. In addition, provide any necessary explanation of the way your State records data or interprets the indices in columns 6 and 7.

Treatment Needs Assessment Summary Matrix

State:

Calendar Year _______

1. Substate planning area

2. Total population

3. Total population in need

4. Number of IVDUs in need

5. Number of women in need

6. Prevalence of substance-related criminal activity

7. Incidence of communicable diseases

A. Needing treatment services

B. That would seek treatment

A. Needing treatment services

B. That would seek treatment

A. Needing treatment services

B. That would seek treatment

A. Number of DWI arrests

B. Number of drug-related arrests

C. Other (specify): _________

A. Hepatitis B/ 100,000

B. AIDS/ 100,000

C. Tubercu- losis/ 100,000

3. Needs by age, sex, and race/ethnicity (Form 9).

Form 9’s intent is to capture in column A the Total number of persons in need of treatment and then have this disaggregated among age, gender and race-ethnicity. This item requires completion of one worksheet for treatment (Form 9). The form is self-explanatory, distributing the populations by age, sex, and race-ethnicity. The total of columns B through H should equal the total reported in column A (this total should also equal the sum of columns I and J).

These data aggregations by race and ethnicity are the categories required by the October 30, 1997 revision of OMB Statistical Policy Directive No. 15: Race and Ethnic Standards for Federal Statistics and Administrative Reporting (http://www.whitehouse.gov/omb/fedreg/ombdir15.html

Treatment Needs by Age, Sex, and Race/Ethnicity

State:

Sex and Race/Ethnicity

Age

A. TOTAL

B. WHITE

C. BLACK OR AFRICAN AMERICAN

D. NATIVE HAWAIIAN/ OTHER PACIFIC ISLANDER

E. ASIAN

F. AMERICAN INDIAN / ALASKA NATIVE

G. MORE THAN ONE RACE REPORTED

H. UNKNOWN

I. NOT HISPANIC OR LATINO

J. HISPANIC OR LATINO

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

1. 17 & Under

2. 18-24

3. 25-44

4. 45-64

5. 65 and over

6. Total

How your State determined the estimates for Form 8 and Form 9

Under 42 U.S.C. 300x-29 and 45 C.F.R. 96.133, States are required to submit annually a needs assessment. This requirement is not contingent on the receipt of Federal needs assessment resources. States are required to use the best available data. Using up to three pages, explain what methods your State used to estimate the numbers of people in need of substance abuse treatment services, the biases of the data, and how the State intends to improve the reliability and validity of the data. Also indicate the sources and dates or timeframes for the data used in making these estimates reported in both Forms 8 and 9. In addition, provide any necessary explanation of the way your State records data or interprets the indices in columns 6 and 7, Form 8.

4. Intended use plan (Form 11)

This item requires the completion of the Intended Use Plan (Form 11). The form is similar to the Substance Abuse State Agency Spending Report (Form 4) that you completed in Section II of the application. To complete Row 1 through Row 6, please refer to the instructions for Form 4 found on page 40.³

 Row 1: Total expenditures for substance abuse treatment and rehabilitation Row 1: SAPT Block Grant funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services – Enter the amount of funds from the FY 2008 award for this purpose. This includes funds used for alcohol and drug prevention (other than primary prevention) and treatment activities. This also includes direct services to patients, such as outreach, detoxification, methadone detoxification and maintenance, outpatient counseling, residential rehabilitation including therapeutic community stays, hospital-based care, vocational counseling, case management, central intake, and program administration. Early intervention activities (other than primary prevention), substance abuse treatment and rehabilitation activities should be included as part of row 1. Do not include funds for

administration cost in this row.

Row 2: Primary Prevention

Row 3: Tuberculosis Services

Row 4: HIV Early Intervention Services

Row 5: Administration

Row 6: Column Total

.

Instructions for columns A through F: Remember to enter only those funds to be spent by the agency administering the FY 20087 SAPT Block Grant and to enter figures in whole dollar amounts.

 Most States report that they use the full 24-month period to spend block grant funds. The intent is to determine how much funding from other sources is available to the principal agency of the State for substance abuse prevention and treatment services during the same period. Even if your State plans to spend the FY 20087 award in less than 24 months, report for the full 24-month period in columns B through F.

Column A: FY 20087 SAPT Block Grant – Enter the amounts of FY 20087 block grant funds your State plans to spend on each activity. Base your entities on the amount allocated under the President’s FY 20087 Budget Request. This budget has not yet been approved and is only an estimate. Those estimates are provided on pages 147XXX-XXXCSAT-21 and CSAT-22 of the FY 2008 Justification of Estimates for Appropriations Committees (http://www.samhsa.gov/Budget/FY2008/SAMHSA08CongrJust.pdf ). Definitions of the funding sources in columns B through F were provided in the instructions for Form 4 in Section II of this application.-150.

Column B: Medicaid – Base your entries on an estimate of Medicaid funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award.

Column C: Other Federal funds – Base your entries on an estimate of other Federal funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award.

Column D: State funds – Base your entries on an estimate of State funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award.

Column E: Local funds – Base your entries on an estimate of local funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award.

Column F: Other – Base your entries on an estimate of other funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award. Definitions of the funding sources in columns B through F were provided in the instructions for Form 04 in Section II of this application.

Intended Use Plan (Include ONLY funds to be spent by the agency administering the block grant. Estimated data are acceptable on this form.)
State:	Source of Funds
	(24 Month Projection)
Activity (See instructions for using Row 1.)	A. FY 20087 SAPT Block Grant	B. Medicaid (Federal, State, and local)	C. Other Federal Funds (e.g., Medicare, other public welfare)	D. State funds	E. Local funds (excluding local Medicaid)	F. Other
Substance Abuse Prevention* and Treatment and Rehabilitation
2. Primary Prevention
Tuberculosis Services
HIV Early Intervention Services
5. Administration (excluding program / provider level)
6. Column Total

* Prevention other than Primary Prevention

Form 11a and 11b: Detailing planned expenditures on primary prevention (Form 11, Row 2) of Form 11

Primary prevention activities are those directed at individuals who do not require treatment for substance abuse. In implementing the comprehensive primary prevention program, the State shall use a variety of strategies including but not limited to the six strategies listed below following. If a State employs strategies not covered by these six categories, please report them under “Other” in a separate row for each one in Form 11a, or the State may choose to report activities utilizing the IOM Model of Universal Selective and Indicated in Form 11b. If a State chooses to complete Form 11b , Form 11a, Section 1926 – Tobacco row must be completed. PLEASE NOTE CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

1. Information Dissemination: This strategy provides awareness and knowledge of the nature and extent of alcohol, tobacco and drug use, abuse and addiction and their effects on individuals, families and communities. It also provides knowledge and awareness of available prevention programs and services. Information dissemination is characterized by one-way communication from the source to the audience, with limited contact between the two. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Clearinghouse/information resource center(s);

(ii) Resource directories;

(iii) Media campaigns;

(iv) Brochures;

(v) Radio/TV public service announcements;

(vi) Speaking engagements;

(vii) Health fairs/health promotion; and

(viii) Information line.

(2) Education: This strategy involves two-way communication and is distinguished from the Information Dissemination strategy by the fact that interaction between the educator/facilitator and the participants is the basis of its activities. Activities under this strategy aim to affect critical life and social skills, including decision-making, refusal skills, critical analysis (e.g., of media messages) and systematic judgment abilities. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Classroom and/or small group sessions (all ages);

(ii) Parenting and family management classes;

(iii) Peer leader/helper programs;

(iv) Education programs for youth groups; and

(v) Children of substance abusers groups.

(3) Alternatives: This strategy provides for the participation of target populations in activities that exclude alcohol, tobacco and other drug use. The assumption is that constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by alcohol, tobacco and other drugs and would, therefore, minimize or obviate resort to the latter. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Drug free dances and parties;

(ii) Youth/adult leadership activities;

(iii) Community drop-in centers; and

(iv) Community service activities.

(4) Problem Identification and Referral: This strategy aims at identification of those who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted, however, that this strategy does not include any activity designed to determine if a person is in need of treatment. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Employee assistance programs;

(ii) Student assistance programs; and

(iii) Driving while under the influence/driving while intoxicated education

programs.

(5) Community-Based Process: This strategy aims to enhance the ability of the community to more effectively provide prevention and treatment services for alcohol, tobacco and drug abuse disorders. Activities in this strategy include organizing, planning, enhancing efficiency and effectiveness of services implementation, inter-agency collaboration, coalition building and networking. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Community and volunteer training, e.g., neighborhood action training,

training of key people in the system, staff/officials training;

(ii) Systematic planning;

(iii) Multi-agency coordination and collaboration;

(iv) Accessing services and funding; and

5. Community team-building.

(6) Environmental: This strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of the abuse of alcohol, tobacco and other drugs used in the general population. This strategy is divided into two subcategories to permit distinction between activities which center on legal and regulatory initiatives and those that relate to the service and action-oriented initiatives. Examples of activities conducted and methods used for this strategy shall include (but not be limited to) the following:

(i) Promoting the establishment or review of alcohol, tobacco and drug use

policies in schools;

(ii) Technical assistance to communities to maximize local enforcement procedures governing availability and distribution of alcohol, tobacco, and other drug use;

(iii) Modifying alcohol and tobacco advertising practices; and

(iv) Product pricing strategies.

7. Other: The six primary prevention strategies have been designed to encompass nearly all of the prevention activities. However, in the unusual case an activity does not fit one of the six strategies it may be classified in the “Other” category.

Section 1926 - Tobacco

(8) Costs Associated with the Development and Conduct of Random, Unannounced Tobacco Inspections- Costs Associated with the Synar program. Per Jan. 19, 1996, 45 CFR Part 96, Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants; Final Rule, States may not use the Block Grant to fund the enforcement of their statute, except that they may expend funds from their primary prevention set aside of their Block Grant allotment under 45 CFR 96.124(b)(1) for carrying out the administrative aspects of the requirements such as the development of the sample design and the conducting of the inspections.

States should include any non-SAPT funds that were allotted for Synar activities in the appropriate columns.

include aggregate costs associated with carrying out the administrative aspects of the requirements such as the development of the sample design and the conducting of the inspections.

In addition, prevention strategies may be classified using the IOM Model of Universal, Selective and Indicated. Here are the definitions of those strategies. PLEASE NOTE: CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

Primary Prevention Expenditures Checklist

Institute of Medicine Classification: Universal Selective and Indicated:

Universal: Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

Universal Direct. Row 1—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions)

Universal Indirect. Row 2—Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices).This also could include interventions involving programs and policies implemented by coalitions.

• Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels. (Adapted from The Institute of Medicine)

Form 11a: Primary Prevention Planned Expenditures Checklist

Estimated data are acceptable in this checklist.

Block Grant Other

FY 20087 Federal State Local Other

 Information

Dissemination $ $ $ $ $_____

 Education $ $ $ $ $_____

 Alternatives $ $ $ $ $_____

 Problem

Identification

and Referral $ $ $ $ $_____

 Community-

based Process $ $ $ $ $_____

 Environmental $ $ $ $ $_____

 Other $ $ $ $ $_____

 Section 1926- $ $ * $ * $ * $_____

Tobacco

TOTAL $ $ $ $ $

*Please list all sources, if possible (e.g., Center for Disease Control and Prevention block grant, foundations).

Form 11b: Primary Prevention Planned Expenditures Checklist

Estimated data are acceptable in this checklist.

Block Grant Other

FY 2008 Federal State Local Other

 Universal

Direct $ $ $ $ $_____

• Universal

• Indirect $ $ $ $ $_____

 Selective $ $ $ $ $_____

 Indicated $ $ $ $ $_____

TOTAL $ $ $ $ $

*Please list all sources, if possible (e.g., Center for Disease Control and Prevention block grant, foundations).

Resource Development Planned Expenditure Checklist (Form 11cb)

How to report planned expenditures on substance abuse resource development activities.

Your State may plan to spend FY 20087 block grant funds on substance abuse resource development activities. These kinds of activities were described in Section II. Complete the following checklist:

Does your State plan to fund resource development activities with FY 20087 funds?

 Yes  No

If yes, show the estimated amounts that will be spent in the table below:

Additional

Treatment Prevention Combined Total

 Planning, coordination, $ $ $ $________

and needs assessment

 Quality assurance $ $ $ $________

 Training (post-employment) $ $ $ $________

 Education (pre-employment) $ $ $ $________

 Program development $ $ $ $________

 Research and evaluation $ $ $ $________

 Information systems $ $ $ $________

TOTAL $ $ $ $

Remember that resource development expenditures are not limited to row 5, Form 11 (Administration). You may plan resource development expenditures from rows 1 through 5.

5. Treatment Capacity Matrix (Form 12)

This involves completion of the Treatment Capacity Matrix (Form 12). It is identical to Form 7aA, except that you enter information about the 24-month period during which your principal agency of the State is permitted to spend the FY 20087 block grant award and no cost data is enetered. This This Form coversis the same period covered on the Intended Use Plan (Form 11), and you have already estimated how much money the principal agency of the State will obligate and spend. The definitions are as follows:

DETOXIFICATION (24-HOUR CARE)

Row 1: Hospital inpatient – Twenty-four hour/day medical acute care services for detoxification for persons with severe medical complications associated with withdrawal.

Row 2: Free-standing residential – Twenty-four hour/day services in a non-hospital setting that provide for safe withdrawal and transition to ongoing treatment.

REHABILITATION/RESIDENTIAL

Row 3: Hospital inpatient - Twenty-four hour/day medical care (other than detoxification) in a hospital facility in conjunction with treatment services for alcohol and other drug abuse and dependency.

Row 4: Short-term (up to 30 days) – Short-term residential, typically 30 days or less of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency.

Row 5: Long-term (over 30 days) - Long-term residential, typically over 30 days of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency (may include transitional living arrangements such as halfway houses).

AMBULATORY (OUTPATIENT)

Row 6: Outpatient – Treatment/recovery/aftercare or rehabilitation services provided where the patient does not reside in a treatment facility. The patient receives drug abuse or alcoholism treatment services with or without medication, including counseling and supportive services. Day treatment is included in this category. This also is known as nonresidential services in the alcoholism field.

Row 7: Intensive outpatient – Services provided to a patient that last two or more hours per day for three or more days per week.

Row 8: Detoxification – Outpatient treatment services rendered in less than 24 hours that provide for safe withdrawal in an ambulatory setting (pharmacological or non-pharmacological).

Row 9: Opioid Replacement Therapy - Report the number of clients for whom it is planned to use opioid replacement therapy during their course of treatment.

Column A: Report the number of planned admissions (total admissions) for each of the nine levels of care.

Column B: Report the unduplicated number of persons to be served within the number of planned admissions. Note that Column B is a subset of column A. For planning purposes, the planned number of clients to be served during the 24-month period covered in Form 12 State Expenditure Period are counted only once in each applicable level orf care, even if it is expected that these clients may terminate and be readmitted during the 24-month time period.

Treatment Capacity Matrix
This form contains data covering a 24- month projection for the period during which your principal agency of the State is permitted to spend the FY 2008 7 block grant award.
STATE:
LEVEL OF CARE	A. Number of Admissions	B. Number of Persons Served
Detoxification (24-Hour Care)
1. Hospital Inpatient
2. Free-Standing Residential
Rehabilitation/Residential
3. Hospital Inpatient
4. Short-term (up to 30 days)
5. Long-term (over 30 days)
Ambulatory (Outpatient)
6. Outpatient
7. Intensive Outpatient
8. Detoxification
9. Opioid Replacement TherapyMethadone

6. Purchasing services

This item requires completing two checklists.

Methods for Purchasing

There are many methods the State can use to purchase substance abuse services. Use the following checklist to describe how your State will purchase services with the FY 20087 block grant award. Indicate the proportion of funding that is expended through the applicable procurement mechanism.

• Competitive grants Percent of Expense_____

• Competitive contracts Percent of Expense_____

• Non-competitive grants Percent of Expense_____

• Non-competitive contracts Percent of Expense_____

 Statutory or regulatory allocation to Percent of Expense_____

governmental agencies serving as

umbrella agencies that purchase or

directly operate services

• Other Percent of Expense_____

Total: 100%

(The total for the above categories should equal 100 percent.)

 According to county or Percent of Expense_____

regional priorities

Methods for Determining Prices

There are also alternative ways a State can decide how much it will pay for services. Use the following checklist to describe how your State pays for services. Complete any that apply. In addressing a State’s allocation of resources through various payment methods, a State may choose to report either the proportion of expenditures or proportion of clients served through these payment methods. Estimated proportions are acceptable.

 Line item program budget Percent of Clients Served_____

Percent of Expenditures______

 Price per slot Percent of Clients Served_____

Percent of Expenditures______

Rate: Type of slot:

Rate: Type of slot:

Rate: Type of slot:

 Price per unit of service Percent of Clients Served_____

Percent of Expenditures______

Unit: Rate:

Unit: Rate:

Unit: Rate:

 Per capita allocation (Formula): Percent of Clients Served_____

Percent of Expenditures_____

 Price per episode of care: Percent of Clients Served_____

Percent of Expenditures_____

Rate: Diagnostic group:

Rate: Diagnostic group:

Rate: Diagnostic group

7. Program performance monitoring

The purpose of this item is to document how the principal agency of the State will monitor and evaluate the performance of substance abuse service providers that receive State and/or block grant funds. Use the following checklist to indicate what methods your State uses. Check all that apply. When you are asked for frequency in the items below, use the following choices:

• monthly

• quarterly

• semi-annually

• annually

• every two years

 On-site inspections

Frequency for treatment: ( )

Frequency for prevention: ( )

 Activity reports

Frequency for treatment: ( )

Frequency for prevention: ( )

 Management information system

 Patient/participant data reporting system

Frequency for treatment: ( )

Frequency for prevention: ( )

 Performance contracts

 Cost reports

 Independent peer review

 Licensure standards - programs and facilities

Frequency for treatment: ( )

Frequency for prevention: ( )

 Licensure standards - personnel

Frequency for treatment: ( )

Frequency for prevention: ( )

 Other (Specify): .

SECTION IVa-A

VOLUNTARY TREATMENT PERFORMANCE MEASURES

INSTRUCTIONS

TREATMENT MEASURES

Data is requested on the following forms:

Form T1 – Employment Status

Form T2 – Living Status

Form T3 – Criminal Justice Involvement

Form T4 – Alcohol Use

Form T5 – Other Drug Use

Form T6 – Social Support of Recovery

Form T7 - Retention

GENERAL INSTRUCTIONS FOR VOLUNTARY FORMS T1-T7:

SAMHSA is interested in demonstrating program accountability and efficacy through the National Outcome Measures (NOMs). The NOMs are intended to document the performance of Federally supported programs and systems of care. The following set of instructions and optional forms are intended to collectavailable for States’ NOMs or treatment performance measures. States using the Web-based Block Grant Application System (Web BGAS)BGAS may either wish to elect to use pre-populated data forms based on analyses of their Treatment Episode Dataset or may wish to complete these forms independently. States using the MS Word version will need to complete these forms independently. The State’s use of such data should then be discussed in the accompanying narratives addressing State Performance Management and Leadership and Provider Involvement.

It is understood that, at the current time, not all States have the infrastructure in place that supports the reporting of such data. If States cannot report such data, States must communicate their current capacity to report on the proposed SAPTBG supported program performance measures, a clear explanation of the State’s problem in obtaining the data, what barriers exist and the State time-framed plan to collect and report this data. Such information is critical to inform future activities leading towards full implementation of the performance-based Block Grant Program.

to complete on a voluntary basis. It is understood that, at the current time, not all States have the infrastructure in place that supports the reporting of such data. By participating on a voluntary basis, States can communicate their current capacity to report on the proposed SAPTBG supported program performance measures and will thus help inform future activities leading towards full implementation of the performance-based Block Grant Program.

If a State is using the Web-based Block Grant Application System (Web BGAS), the State may elect the option to have the treatment performance measure forms automatically pre-populated with data already submitted to SAMHSA through the Drug Aabuse Services Information System, Treatment Episode Data Set/State Outcome Measurement and Monitoring System (DASIS/TEDS/SOMMS). Web BGAS provides instructions for viewing your State’s data and for electing to have your performance measures pre-populated.

The specifications for pre-populating the application for treatment NOMS data previously submitted SAMHSA by participating in the DASIS/TEDS/SOMMS program are provided below:

Pre-populated data will be reported separately for the four major levels of care defined in the SAMHSA TEDS program (i.e., outpatient, intensive outpatient, short- and long- term residential);

All records from providers that do not receive public funding will be excluded to the extent that the State identifies them to SAMHSA, and;

All change measures will be directly calculated by subtraction representing direct change.

If a State elects to pre-populate Performance Measure tables T1-T5,and T7, Web -BGAS will pre-populate all tables for which SAMHSA has received adequate data from the State through DASIS/TEDS/SOMMS. These pre-populated tables will be used for the purposes of completing the section as well as for external reporting.

If a State chooses to complete these tables independently, the following instructions should be used.

1. Include all “Primary Clients” who received services from treatment programs that received some or all of their funding from the Substance Abuse Prevention and Treatment Block Grant. Do not include family members or other persons collaterally involved in the clients’ treatment. Include only persons actually admitted to treatment, excluding those who received detoxification, outreach, early intervention or assessment/Central Intake services but who did not enter treatment. In addition to completing the T tables as described by the directions above, aA State may wish to report on specific modalities or populations separately such as outpatient, residential and opioidate replacement therapy or treatment completers versus non-completers. The State is asked to clearly identify how and why such distinctions are made. The State should discuss how it addressed tracking clients receiving opioidate replacement therapy/pharmacotherapy in their State and provide a description in the State Description of Data Collection form.

2. Report data for the most recent yearState Fiscal Year for which the data are available at the time the application is submitted on Forms T1-T7. In no case should the reporting year be earlier than the year for which the State is reporting SAPT Block Grant expenditures in the application being submitted. Enter the 12 month period reported in each Form in the space providedIndicate the State Fiscal Year chosen for reporting in the appropriate place on the form.

3. Report data on all clients who have a discharge record in the reporting year. All clients with treatment periods that ended in the reporting year (i.e., clients who did not receive subsequent treatment in 30 days) should have a discharge record.

4. Please complete each form if possible. If States cannot report such data, States must communicate their current capacity to report on the proposed SAPTBG supported program performance measures, a clear explanation of the State’s problem in obtaining the data, what barriers exist and the State time-framed plan to collect and report this data.

5. Forms T1-T6 collect data on the number and percent of clients for the characteristics of interest (i.e., employment status, homelessness, etc.) at admission and discharge. If possible, the State should report based on Treatment Episode. In Episode based reporting, admission is defined as occurring on the first date of service in a program/service delivery unit prior to which no services have been received from any program/service delivery unit for 30 days. Discharge is defined as occurring on the last date on which the client received service from a program/service delivery unit, subsequent to which the client received no services from any program/service delivery unit for 30 days. For example, a client may present for detoxification 29 days after being discharged from an intensive outpatient program. If possible, that client’s treatment in detoxification and subsequent levels of care, if any, should be linked to the prior service(s) record(s) up to the point where a client had an uninterrupted 30 day period in which no services were received. If a client presented for treatment 32 days after being discharged from a previous treatment service, a new episode of care would begin.

If a State is unable to report on an episode basis, it should report the basis it has used for producing the reported data. For example, the State may only be able to report data based on Modalities/Levels of Care. The State should also discuss the specific approach used to define admission and discharge within this framework.

6. For Forms T1-T6each table, please respond to the questions related to data source, e.g., how admission and discharge basis are defined, how admission and discharge data are collected, how admission and discharge data are linked, and whether or not the State is able to collect such data.

INSERT OVERALL NARRATIVE:

The State should address as many of these questions as possible and may provide other relevant information if so desired. Responses to questions that are already provided in other sections of the application (e.g., planning, needs assessment) should be referenced whenever possible.

State Performance Management and Leadership

Describe the Single State Authority capacity and capability to make data driven decisions based on performance measures? Describe any potential barriers and necessary changes that would enhance the SSA’s leadership role in this capacity.

Describe the types of regular and ad hoc reports generated by the State and identify to whom they are distributed and how.

If the State sets benchmarks, performance targets or quantified objectives, what methods are used by the State in setting these values?

What actions does the State take as a result of analyzing performance management data?

Has the State developed evidence-based practices (EBPs) or programs and, if so, does the State require that providers use these EBPs?

Provider Involvement

What actions does the State expect the provider or intermediary to take as a result of analyzing performance management data?

If the SSA has a regular training program for State and provider staff that collect and report client information, describe the training program, its participants and frequency.

Do workforce development plans address NOMs implementation and performance-based management practices?

Does the State require providers to supply information about the intensity or number of services received?

FORM T1– TREATMENT PERFORMANCE MEASURE

EMPLOYMENT STATUS (From Admission to Discharge)

Most recent State fiscal year for which data are available: _____________

Employment Status – Clients employed (full-time or part-time) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients employed (full-time and part-time) [numerator]
Total number of clients with non-missing values on employment status [denominator]
Percent of clients employed (full-time and part-time)
Percent of clients employed (full-time or part-time) at discharge minus percent of clients employed at admission. Absolute Change [%T2-%T1] _________ Relative Change [(%T2-%T1)/% T1] x 100 ______ (Positive percent change values indicate increased employment)
Note: If Web-BGAS is used, the absolute percentage point change and relative per cent change will be calculated automatically.

The section below should be completed at the time data is entered in the table above

T1.1 Client Self Report

What is the source of data for Administrative Data Source

this table? (Select all that apply) Other: Specify___________________________

T1.2 Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) Admission is on the first date of service in a Program/ Service Delivery Unit AND Discharge is on the last date of service in a Program/ Service Delivery Unit

Other: Specify_________________________________________________________________________________________________________________________________

T1.3 Not Applicable, data reported on form is collected at time period other than discharge

 Specify: In-Treatment data ____days post admission OR Follow-up data __months. Post admission discharge Other: Specify_______

How was the discharge data Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment

collected? Discharge data is collected for a sample of all clients who were admitted to treatment

(Select all that apply) Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment

Discharge records are NOT completed for some clients who were admitted to treatment

Specify proportion of admitted clients with a discharge record: __________%

T1.4 Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID).

Select type of UCID:

Was the admission and Master Client Index or Master Patient Index, centrally assigned

discharge data linked? Social Security Number

(Select all that apply) Unique client ID based on fixed client characteristics (such as DOB, gender, partial SSN, etc.)

Some other Statewide unique ID
Provider-entity-specific unique ID

No, State Management Information System does not utilize a UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a

cohort basis) or State relied on other data sources for post admission data

No, admission and discharge records were matched using probabilistic record matching

T1.5 Not Applicable, data reported above

Why are you Unable to Report? Information is not collected at Admission Information is not collected at Discharge Information not collected by categories requested

(Select all that apply) State collects information on the indicator area but utilizes a different measure Other: Specify_______________________________________

Performance Measure Data Collection

Interim Standard – Change in Employment Status

(from Admission to Discharge)

GOAL	To improve the employment status of persons treated in the State’s substance abuse treatment system.
MEASURE	The change in all clients receiving treatment who reported being employed (including part-time) at discharge.
DEFINITIONS	Change in all clients receiving treatment who reported being employed (including part-time) at admission and discharge.

For example:

If the State enters data such as is entered in the table below, the data can be used to calculate both an absolute percentage point change and a relative change.

Employment Status - Clients employed (full-time and part-time) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)		Difference
				Absolute Change
Number of clients employed (full-time and part-time) [numerator] [e.g., TEDS codes 01 and 02]	12,876	13,598
Total number of clients with non-missing values on employment status [denominator] [e.g., any valid TEDS codes 01-04, x 97-98]	26,208	26,208
Percent of clients employed (full-time and part-time)	49.1%	51.9%		2.8%

Thus there was a 2.8 percentage point increase (absolute change) in the proportion of clients employed.

[%T₂-%T₁] [51.9%-49.1%] = 2.8%

The relative increase in the proportion of clients employed is 5.7 percent.

[(%T₂-%T₁)/ %T₁] x 100 [(51.9%-49.1%)/49.1%] x 100 = 5.7%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to Objective 26-8 (Developmental): Reduce the cost of lost productivity in the workplace due to alcohol and drug use.
INTERIM STANDARD FOR DATA COLLECTION	Data related to employment status should be collected using the relevant Treatment Episode Data Set (TEDS) element at admission and discharge. States report on number and proportion of clients employed from the 30 days preceding admission to treatment, to the 30 days preceding discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. “Employed” includes those employed full time (35 or more hours per week) and part time (less than 35 hours per week). Exclude those not in the labor force, including, homemakers, students, those disabled, retired persons, those not looking for work in the last 30 days and those in institutions.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data (e.g., TEDS, Addiction Severity Index (ASI), ASI-Lite, etc.).
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T1

State Description of Employment Status Data Collection (Form T1)

GOAL	To improve the employment status of persons treated in the States substance abuse treatment systems.
MEASURE	The change in all clients receiving treatment who reported being employed (including part-time) at discharge
STATE CONFORMANCE TO INTERIM STANDARD	State Description of Employment Data Collection (Form T1): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T1 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________State collects admission data. YES____________ NO__________
EPISODE OF CARE	How is the admission/discharge basis defined for table T1 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________ State collects discharge data. YES____________ NO__________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T1 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment State collects admission and discharge data on employment that can be reported using TEDS definitions. YES____________ NO__________
RECORD LINKING	Was the admission and discharge data linked for table T1(select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.State reported data using data other than admission and discharge data. YES____________ NO__________
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.State reported data using administrative data. YES____________ NO__________
DATA PLANS IF DATA IS NOT AVAILABLEDATA SOURCE(S)	State must provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost. Source(s):
DATA ISSUES	Issues:
DATA PLANS IF DATA IS NOT AVAILABLE	State should provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T2–TREATMENT PERFORMANCE MEASURE

HOMELESSNESS: Living Status (From Admission to Discharge)

Most recent State fiscal year for which data are available: _____________

Homelessness – Clients homeless (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients homeless [numerator]
Total number of clients with non-missing values on living arrangements [denominator]
Percent of clients homeless
Percent of clients homeless at discharge minus percent of clients homeless at admission Absolute Change [%T2-%T1] _________ Relative Change [(%T2-%T1)/% T1] x 100 ______ Negative percent change values indicate reduced homelessness
Note: If Web-BGAS is used, the absolute percentage point change and relative per cent change will be calculated automatically.

The section below should be completed at the time data is entered in the table above

T2.1 Client Self Report

What is the source of data for Administrative Data Source

this table? (Select all that apply) Other: Specify___________________________

T2.2 Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) Admission is on the first date of service in a Program/ Service Delivery Unit AND Discharge is on the last date of service in a Program/ Service Delivery Unit

Other: Specify_________________________________________________________________________________________________________________________________

T2.3 Not Applicable, data reported on form is collected at time period other than discharge

 Specify: In-Treatment data ____days post admission OR Follow-up data __months. Post admission discharge Other: Specify_______

How was the discharge data Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment

collected? Discharge data is collected for a sample of all clients who were admitted to treatment

(Select all that apply) Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment

Discharge records are NOT completed for some clients who were admitted to treatment

Specify proportion of admitted clients with a discharge record: __________%

T2.4 Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID).

Select type of UCID:

Was the admission and Master Client Index or Master Patient Index, centrally assigned

discharge data linked? Social Security Number

(Select all that apply) Unique client ID based on fixed client characteristics (such as DOB, gender, partial SSN, etc.)

Some other Statewide unique ID
Provider-entity-specific unique ID

No, State Management Information System does not utilize a UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a

cohort basis) or State relied on other data sources for post admission data

No, admission and discharge records were matched using probabilistic record matching

T2.5 Not Applicable, data reported above

Why are you Unable to Report? Information is not collected at Admission Information is not collected at Discharge Information not collected by categories requested

(Select all that apply) State collects information on the indicator area but utilizes a different measure Other: Specify_______________________________________

Performance Measure Data Collection

Performance Measure Data Collection

Interim Standard – Number of Clients and Change in Homelessness (Living Status)

GOAL	To improve living conditions of persons treated in the State’s substance abuse treatment system.
MEASURE	The change of all clients receiving treatment who reported being homeless at discharge.
DEFINITIONS	Change of all clients receiving treatment who reported being homeless at discharge equals the clients reporting being homeless at admission subtracted from the clients reporting being homeless at discharge.

For example:

If the State enters data such as is entered in the table below, the data can be used to calculate both an absolute percentage point change and a relative change.

Homelessness - Clients homeless (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)		Difference
				Absolute Change
Number of clients homeless [numerator] [e.g., TEDS supplemental code 01]	1,056	900
Total number clients with non-missing values on living arrangements [denominator] [e.g., TEDS supplemental codes 01-03 x 97-98]	29,033	29,033
Percent of clients homeless	3.6%	3.1%		-0.5%

Thus, there was 0.5 percentage point decrease (absolute change) in the proportion of clients who were homeless.

[%T₂-%T₁] [3.1%-3.6%] = -0.5%

The relative decrease in the proportion of clients who were homeless is 13.8 percent.

[(%T₂-%T₁)/%T₁] x 100 [(3.1%-3.6%)/3.6%] x 100 = -13.8%

HEALTHY PEOPLE 2010 OBJECTIVES	No Related Objectives
INTERIM STANDARD FOR DATA COLLECTION	Data related to living status should be collected using the relevant Treatment Episode Data Set (TEDS) element at admission and discharge. The reported measure will reflect differences in homelessness at admission to treatment, and at discharge. States should track client-level data by matching admission to discharge records through a unique statewide client ID. TEDS defines homeless as clients with no fixed address; includes shelters. Continued on next page > Dependent living (at risk for being homeless) is defined as clients living in a supervised setting such as a residential institution, halfway house or group home.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data (e.g., TEDS, Addiction Severity Index (ASI), ASI-Lite, etc.).
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T2

State Description of Homelessness (Living Status) Data Collection (Form T2)

GOAL	To improve living conditions of persons treated in the State’s substance abuse treatment system.
MEASURE	The change in all clients receiving treatment who reported being homeless at discharge.
STATE CONFORMANCE TO INTERIM STANDARD	State Description of Homelessness (Living Status) Data Collection (Form T2): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T2 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________State collects admission data. YES____________ NO__________
EPISODE OF CARE	How is the admission/discharge basis defined for table T2 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________ State collects discharge data. YES____________ NO__________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T2 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment State collects admission and discharge data on living status that can be reported using TEDS definitions. YES____________ NO__________
RECORD LINKING	Was the admission and discharge data linked for table T2 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.State reported data using data other than admission and discharge data. YES____________ NO__________
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.State reported data using administrative data. YES____________ NO__________
DATA PLANS IF DATA IS NOT AVAILABLEDATA SOURCE(S)	State must provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost. Source(s):
DATA ISSUES	Issues:
DATA PLANS IF DATA IS NOT AVAILABLE	State should provide time-framed plans for capturing living status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T3– TREATMENT PERFORMANCE MEASURE

CRIMINAL JUSTICE INVOLVEMENT (From Admission to Discharge)

Most recent State fiscal year for which data are available: _____________

Arrests – Clients arrested (any charge) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of Clients arrested [numerator]
Total number of clients with non-missing values on arrests [denominator]
Percent of clients arrested
Percent of clients arrested at discharge minus percent of clients arrested at admission Absolute Change [%T2-%T1] ______________ Relative Change [(%T2-%T1)/%T1] x 100__________ Negative percent change values indicate reduced arrests
Note: If Web-BGAS is used, the absolute percentage point change and relative per cent change will be calculated automatically.

The section below should be completed at the time data is entered in the table above

T3.1 Client Self Report

What is the source of data for Administrative Data Source

this table? (Select all that apply) Other: Specify___________________________

T3.2 Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service how is

How is the Admission/Discharge Admission/Discharge has been received for 30 days

Basis defined? (Select one) Admission is on the first date of service in a Program/ Service Delivery Unit AND Discharge is on the last date of service in a Program/ Service Delivery Unit

Other: Specify______________________________________________________________________________________________________________________________________

T3.3 Not Applicable, data reported on form is collected at time period other than discharge

How was the discharge data Specify: In-Treatment data _____days post admission OR Follow-up data ___months. Post admission discharge Other: Specify ______

collected? Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment

(Select all that apply) Discharge data is collected for a sample of all clients who were admitted to treatment

Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment

Discharge records are NOT completed for some clients who were admitted to treatment.

Specify proportion of clients without a discharge record: __________%

T3.4 Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID).

Select type of UCID:

Was the admission and Master Client Index or Master Patient Index, centrally assigned

discharge data linked? Social Security Number

(Select all that apply) Unique client ID based on fixed client characteristics (such as DOB, gender, partial SSN, etc.)

Some other Statewide unique ID
Provider-entity-specific unique ID

No, State Management Information System does not utilize a UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a

cohort basis) or State relied on other data sources for post admission data

No, admission and discharge records were matched using probabilistic record matching

T3.5 Not Applicable, data reported above

Why are you Unable to Report? Information is not collected at Admission Information is not collected at Discharge Information not collected by categories requested State collects information on the indicator area but utilizes a different measure Other: Specify____________________________

Performance Measure Data Collection

Interim Standard –Change of Persons Arrested

GOAL	To reduce the criminal justice involvement of persons treated in the State’s substance abuse treatment system.
MEASURE	The change in persons arrested in the last 30 days at discharge for all clients receiving treatment.
DEFINITIONS	Change in persons arrested in the last 30 days at discharge for all clients receiving treatment equals clients who were arrested in the 30 days prior to admission subtracted from clients who were arrested in the last 30 days at discharge. An arrest is any arrest.

For Example:

If the State enters data such as is entered in the table below, the data can be used to calculate both an absolute percentage point change and a relative change.

Arrests - Clients arrested (any charge) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)		Difference
				Absolute Change
Number of clients arrested at admission vs. discharge [numerator] [see no TEDS manualequivalent, see Access to Recovery (ATR) Request for Applications (RFA), Appendix C]	1,617	757
Total number of Admission and Discharge clients with non-missing values on arrests [denominator] [seeno current TEDS manualequivalent, see ATR RFA Appendix C.]	27,789	27,789
Percent of clients arrested at admission vs. discharge	5.8%	2.7%		-3.1%

Thus, there was a 3.1 percentage point decrease (absolute change) in the proportion of clients arrested 30 days prior to discharge.

[%T₂-%T₁] [2.7%-5.8%] = -3.1%

The relative decrease in the proportion of clients arrested 30 days prior to discharge is 53.45 percent.

[(%T₂-%T₁)/%T₁] x 100 [(2.7%-5.8%)/5.8%] x 100 = -53.45%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to Objective 26-8 (Developmental): Reduce the cost of lost productivity in the workplace due to alcohol and drug use. For drug abuse, most (56 percent) of the estimated productivity losses were associated with crime, including incarcerated perpetrators (26 percent) of drug-related crime.
INTERIM STANDARD FOR DATA COLLECTION	States will collect information on the clients with at least one arrest (a dichotomous response item: arrested – yes/no) in the 30 days preceding admission to treatment and the percentage of clients with at least one arrest in the 30 days prior at discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. A client who has one or more arrest counts (not charges) in the past 30 days, is included in this measure.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data. (e.g., TEDS, Addiction Severity Index (ASI), ASI-Lite, etc.)
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T3

State Description of Number of Arrests Data Collection (Form T3)

GOAL	To reduce the criminal justice involvement of persons treated in the State’s substance abuse treatment system.
MEASURE	The change in persons arrested in the last 30 days at discharge for all clients receiving treatment.
STATE CONFORMANCE TO INTERIM STANDARD	States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T3 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________State collects admission data. YES____________ NO__________
EPISODE OF CARE	How is the admission/discharge basis defined for table T3 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________ State collects discharge data. YES____________ NO__________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T3 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment State collects admission and discharge data on criminal justice involvement that can be reported as a Yes/No response. YES____________ NO__________
RECORD LINKING	Was the admission and discharge data linked for table T3 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.State reported data using data other than admission and discharge data. YES____________ NO__________
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.State reported data using administrative data. YES____________ NO__________
DATA PLANS IF DATA IS NOT AVAILABLEDATA SOURCE(S)	State must provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.Source(s):
DATA ISSUES	Issues: States will need to discuss if information on all arrests is not available.
DATA PLANS IF DATA IS NOT AVAILABLE	State should provide time-framed plans for capturing arrest data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T4– PERFORMANCE MEASURE

CHANGE IN ABSTINENCE – ALCOHOL USE (From Admission to Discharge)

Most recent State fiscal year for which data are available: _____________

Alcohol Abstinence – Clients with no alcohol use (all clients regardless of primary problem) (use Alcohol Use in last 30 days field) at admission. vs.. discharge.	Admission Clients (T1)	Discharge Clients (T2)
Number of clients abstinent from alcohol [numerator]
Total number of clients with non-missing values on “used any alcohol” variable [denominator]
Percent of clients abstinent from alcohol
Percent of clients abstinent from alcohol at discharge minus percent of clients abstinent from alcohol at admission Absolute Change [%T2-%T1] ______________ Relative Change [(%T2-%T1)/%T1] x 100__________ (Positive percent change values indicate increased alcohol abstinence)
(1) If State does not have a "used any alcohol" variable, calculate instead using frequency of use variables for all primary, secondary, or tertiary problem codes in which the coded problem is Alcohol (e.g. ,TEDS Code 02)
Note: If Web-BGAS is used, the absolute percentage point change and relative per cent change will be calculated automatically.

The section below should be completed at the time data is entered in the table above

T4.1 Client Self Report Client Self Report confirmed by another source. ➜ If checked, select one confirmation source: Urinalysis, blood test or other biological assay

What is the source of data for Administrative Data Source Other: Specify___________________________ Collateral source

this table? (Select all that apply) Other: Specify__________________________

T4.2 Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) Admission is on the first date of service in a Program/ Service Delivery Unit AND Discharge is on the last date of service in a Program/ Service Delivery Unit

Other: Specify______________________________________________________________________________________________________________________________________

T4.3 Not Applicable, data reported on form is collected at time period other than discharge

Specify: In-Treatment data _____days post admission OR Follow-up data ___months. Post admission discharge Other: Specify ______

How was the discharge data Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment

collected? (Select all that apply) Discharge data is collected for a sample of all clients who were admitted to treatment

Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment

Discharge records are NOT completed for some clients who were admitted to treatment.

Specify proportion of clients without a discharge record: __________%

T4.4 Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID).

Select type of UCID:

Was the admission and Master Client Index or Master Patient Index, centrally assigned

discharge data linked? Social Security Number

(Select all that apply) Unique client ID based on fixed client characteristics (such as DOB, gender, partial SSN, etc.)

Some other Statewide unique ID
Provider-entity-specific unique ID

No, State Management Information System does not utilize a UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a

cohort basis) or State relied on other data sources for post admission data

No, admission and discharge records were matched using probabilistic record matching

T4.5 Not Applicable, data reported above

Why are you Unable to Report? Information is not collected at Admission Information is not collected at Discharge Information not collected by categories requested

(Select all that apply) State collects information on the indicator area but utilizes a different measure Other: ______________________________

Performance Measure Data Collection

Interim Standard – Percentage Point Change in Abstinence - Alcohol Use

GOAL	To reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change in all clients receiving treatment who reported abstinence at discharge.
DEFINITIONS	Change in all clients receiving treatment who reported abstinence at discharge equals clients reporting abstinence at admission subtracted from clients reporting abstinence at discharge.

For example:

If the State enters data such as is entered in the table below, the data can be used to calculate both an absolute percentage point change and a relative change.

Alcohol Abstinence - Clients with no alcohol use (all clients regardless of primary problem) (use Alcohol Use in last 30 days field) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)		Difference
				Absolute Change
Number of clients abstinent from alcohol [numerator] [e.g., TEDS code 01 - no use]	13,530	19,436
Total number of clients with non-missing values on "used any alcohol" variable [denominator] [e.g., TEDS codes 01-05, x 96-98]	27,658	27,658
Percent of clients abstinent from alcohol	48.9%	70.3%		+21.4%

Thus, there was a 21.4 percentage point increase (absolute change) in the proportion of clients who abstained from alcohol 30 days prior to discharge.

[%T₂-%T₁] [70.3%-48.9%] = 21.4%

The relative increase in abstinence from alcohol use is 43.8 percent.

[(%T₂-%T₁)/%T₁] x 100 [(70.3%-48.9%)/48.9%] x 100 = 43.8%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to: Objective 26-9: Increase the age and proportion of adolescents who remain alcohol and drug free; Objective 26-10: Reduce past month use of illicit substances; Objective 26-11: Reduce the proportion of persons engaging in binge drinking of alcoholic beverages; and Objective 26-12: Reduce average annual alcohol consumption.
INTERIM STANDARD FOR DATA COLLECTION	Data related to alcohol use should be collected using the relevant Treatment Episode Data Set (TEDS) elements at admission and discharge to identify primary, secondary, and tertiary alcohol use and the associated frequency of use data. The reported measure will reflect differences in abstinence in the 30 days preceding admission to AOD treatment, and in the 30 days prior to discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. Abstinence from alcohol use is defined as no past month use of alcohol.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data. (e.g., TEDS, Addiction Severity Index (ASI), ASI-Lite, etc.)
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T4

State Description of Alcohol Use Data Collection (Form T4)

GOAL	To reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change of all clients receiving treatment who reported abstinence at discharge.
STATE CONFORMANCE TO INTERIM STANDARD	State Description of Alcohol Use Data Collection (Form T4): State should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T4 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________State collects admission data. YES____________ NO__________
EPISODE OF CARE	How is the admission/discharge basis defined for table T4 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________ State collects discharge data. YES____________ NO__________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T4 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment State collects admission and discharge data on alcohol use that can be reported using TEDS definitions. YES____________ NO__________
RECORD LINKING	Was the admission and discharge data linked for table T4 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.State reported data using data other than admission and discharge data. YES____________ NO__________
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.State reported data using administrative data. YES____________ NO__________
DATA PLANS IF DATA IS NOT AVAILABLEDATA SOURCE(S)	State must provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.Source(s):
DATA ISSUES	Issues:
DATA PLANS IF DATA IS NOT AVAILABLE	State should provide time-framed plans for capturing alcohol use data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T5– PERFORMANCE MEASURE

CHANGE IN ABSTINENCE -- OTHER DRUG USE (From Admission to Discharge)

Most recent State fiscal year for which data are available: _____________

Drug Abstinence – Clients with no drug use (all clients regardless of primary problem) (use Any Drug Use in last 30 days field) at admission vs. discharge.	Admission Clients (T1)	Discharge Clients (T2)
Number of Clients abstinent from illegal drugs [numerator]
Total number of clients with non-missing values on “used any drug” variable [denominator]
Percent of clients abstinent from drugs
Percent of clients abstinent from drugs at discharge minus percent of clients abstinent from drugs at admission Absolute Change [%T2-%T1] ______________ Relative Change [(%T2-%T1)/%T1] x 100__________ Positive percent change values indicate increased drug abstinence.
(2) If State does not have a "used any drug" variable, calculate instead using frequency of use variables for all primary, secondary, or tertiary problem codes in which the coded problem is Drugs (e.g., TEDS Codes 03-20)
Note: If Web-BGAS is used, the absolute percentage point change and relative per cent change will be calculated automatically.

The section below should be completed at the time data is entered in the table above

T5.1 Client Self Report Client Self Report confirmed by another source. ➜ If checked, select one confirmation source: Urinalysis, blood test or other biological assay

What is the source of data for Administrative Data Source Other: Specify___________________________ Collateral source

this table? (Select all that apply) Other: Specify__________________________

T5.2 Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) Admission is on the first date of service in a Program/ Service Delivery Unit AND Discharge is on the last date of service in a Program/ Service Delivery Unit

Other: Specify______________________________________________________________________________________________________________________________________

T5.3 Not Applicable, data reported on form is collected at time period other than discharge

How was the discharge data ➜ Specify: In-Treatment data ____days post admission OR Follow-up data ___months. Post admission discharge Other: Specify_______

collected? (Select all that apply) Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment

Discharge data is collected for a sample of all clients who were admitted to treatment

Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment

Discharge records are NOT completed for some clients who were admitted to treatment

Specify proportion of clients without a discharge record: __________%

T5.4 Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID).

Was the admission and Select type of UCID:

discharge data linked? Master Client Index or Master Patient Index, centrally assigned

(Select all that apply) Social Security Number

Unique client ID based on fixed client characteristics (such as DOB, gender, partial SSN, etc.)

Some other Statewide unique ID
Provider-entity-specific unique ID

No, State Management Information System does not utilize a UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a

cohort basis) or State relied on other data sources for post admission data

No, admission and discharge records were matched using probabilistic record matching

T5.5 Not Applicable, data reported above

Why are you Unable to Report? Information is not collected at Admission Information is not collected at Discharge Information not collected by categories requested

(Select all that apply) State collects information on the indicator area but utilizes a different measure Other: Specify__________________________

Performance Measure Data Collection

Interim Standard – Percentage Point Change in Abstinence – Other Drug Use

GOAL	To reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change of all clients receiving treatment who reported abstinence at discharge.
DEFINITIONS	Change in all clients receiving treatment who reported abstinence at discharge equals clients reporting abstinence at admission subtracted from clients reporting abstinence at discharge.

For example:

If the State enters data such as is entered in the table below, the data can be used to calculate both an absolute percentage point change and a relative change.

Drug Abstinence - Clients with no drug use (all clients regardless of primary problem) (use Any Drug Use in last 30 days field) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)		Difference
				Absolute Change
Number of clients abstinent from illegal drugs [numerator] [e.g., TEDS code 01 - no use]	18,741	21,707
Total number of Admission and Discharge clients with non-missing values on "used any drug" variable [denominator] [e.g., TEDS codes 01-05, x 96-98]	27,668	27,668
Percent of clients abstinent from drugs	67.7%	78.5%		10.8%

Thus, there was a 10.9 percentage point increase (absolute change) in the proportion of clients who used other drugs 30 days prior to discharge.

[%T₂-%T₁] [78.5%-67.7%] = 10.8%

The relative increase in abstinence from use of other drugs is 16 percent.

[(%T₂-%T₁)/%T₁] x 100 [(78.5%-67.7%)/67.7%] x 100 = 16%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to Objective 26-10: Reduce past-month use of illicit substances.
INTERIM STANDARD FOR DATA COLLECTION	Data related to other drug use should be collected using the relevant Treatment Episode Data Set (TEDS) elements at admission and discharge to identify primary, secondary, and tertiary other drug use and the associated frequency of use data. The reported measure will reflect differences in abstinence in the 30 days preceding admission to AOD treatment, and in the 30 days prior to discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. Abstinence from other drug use is defined as no past month use of other drugs.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data. (e.g., TEDS, Addiction Severity Index (ASI), ASI-Lite, etc.)
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T5

State Description of Other Drug Use Data Collection (Form T5)

GOAL	To reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change in all clients receiving treatment who reported abstinence at discharge.
STATE CONFORMANCE TO INTERIM STANDARD	State Description of Other Drug Use Data Collection (Form T5): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T5 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________State collects admission data. YES____________ NO__________
EPISODE OF CARE	How is the admission/discharge basis defined for table T5 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________ State collects discharge data. YES____________ NO__________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T5 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment State collects admission and discharge data on other drug use that can be reported using TEDS definitions. YES____________ NO__________
RECORD LINKING	Was the admission and discharge data linked for table T5 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.State reported data using data other than admission and discharge data. YES____________ NO__________
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.State reported data using administrative data. YES____________ NO__________
DATA PLANS IF DATA IS NOT AVAILABLEDATA SOURCE(S)	State must provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.Source(s):
DATA ISSUES	Issues:
DATA PLANS IF DATA IS NOTAVAILABLE	State should provide time-framed plans for capturing other drug use data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T6 – PERFORMANCE MEASURE

CHANGE IN SOCIAL SUPPORT OF RECOVERY (From Admission to Discharge)

Most recent State fiscal year for which data are available: _____________

Social Support of Recovery – Clients participating in self-help groups, support groups (e.g., AA, NA, etc.) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients with one or more such activities (AA NA meetings attended, etc.) [numerator]
Total number of Admission and Discharge clients with non-missing values on social support activities [denominator]
Percent of clients participating in social support activities
Percent of clients participating in social support of recovery activities in prior 30 days at discharge minus percent of clients participating in social support of recovery activities in prior 30 days at admission. Absolute Change [%T2-%T1] _________ Relative Change [(%T2-%T1)/% T1] x 100 ______ Positive percent change values indicate increased participation in social support of recovery activities.
Note: If Web-BGAS is used, the absolute percentage point change and relative per cent change will be calculated automatically.

The section below should be completed at the time data is entered in the table above

T7.1 Client Self Report

What is the source of data for Administrative Data Source

this table? (Select all that apply) Other: Specify___________________________

T7.2 Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) Admission is on the first date of service in a Program/ Service Delivery Unit AND Discharge is on the last date of service in a Program/ Service Delivery Unit

Other:Specify____________________________________________________________________________________________________________________________________

T7.3 Not Applicable, data reported on form is collected at time period other than discharge

How was the discharge data ➜ Specify: In-Treatment data ____days post admission OR Follow-up data ____months. Post admission discharge Other: Specify_______

collected? (Select all that apply) Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment

Discharge data is collected for a sample of all clients who were admitted to treatment

Discharge records are collected (or in the case of early dropouts) created for all (or almost all) clients who were admitted to treatment

Discharge records are NOT completed for some clients who were admitted to treatment.

Specify proportion of clients without a discharge record: __________%

T7.4 Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID).

Select type of UCID:

Was the admission and Master Client Index or Master Patient Index, centrally assigned

discharge data linked? Social Security Number

(Select all that apply) Unique client ID based on fixed client characteristics (such as DOB, gender, partial SSN, etc.)

Some other Statewide unique ID
Provider-entity-specific unique ID

No, State Management Information System does not utilize a UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a

cohort basis) or State relied on other data sources for post admission data.

No, admission and discharge records were matched using probabilistic record matching

T7.5 Not Applicable, data reported above

Why are you Unable to Report? Information is not collected at Admission Information is not collected at Discharge Information not collected by categories requested

(Select all that apply) State collects information on the indicator area but utilizes a different measure Other: Specify_____________________________

Performance Measure Data Collection

Interim Standard – Percentage Point Change in Social Support of Recovery

GOAL	To improve clients’ participation in social support of recovery activities to reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change of all clients receiving treatment who reported participation in one or more social and or recovery support activity at discharge.
DEFINITIONS	Change of all clients receiving treatment who reported participation in one or more social and recovery support activities at discharge equals clients reporting participation at admission subtracted from clients reporting participation at discharge.

For example:

If the State enters data such as is entered in the table below, the data can be used to calculate both an absolute percentage point change and a relative change.

Social Support of Recovery - Clients participating in self-help groups, support groups (e.g., AA NA etc) (prior 30 days) at admission vs. discharge - T7	Admission Clients (T1)	Discharge Clients (T2)		Difference
				Absolute Change
Number of clients with one or more such activities (AA NA meetings attended, etc.) [numerator] [no TEDS equivalent, see ATR RFA Appendix C.]	6,70111,021	11,0216,701
Total number of Admission and Discharge clients with non-missing values on social support activities [denominator] [no TEDS equivalent, see ATR RFA Appendix C.]	23,106	23,106
Percent of clients participating in social support activities	29.0%47.7%	47.729.0%		-18.7%

Thus , there was an 18.7 percentage point indecrease (absolute change) in the proportion of clients who participated in social support recovery 30 days prior to discharge.

[%T₂-%T₁] [29%-47.7%-29.0%] = -18.7%

The relative decrease in the proportion of clients who participated in social support recovery 30 days prior to discharge is 64.5 percent.

[(%T₂-%T₁)/ %T₁] x 100 [(29%-47.7%)/29%] x 100 = -64.5%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to: Objective 26-9: Increase the age and proportion of adolescents who remain alcohol and drug free; Objective 26-10: Reduce past month use of illicit substances; Objective 26-11: Reduce the proportion of persons engaging in binge drinking of alcoholic beverages; and Objective 26-12: Reduce average annual alcohol consumption.
INTERIM STANDARD FOR DATA COLLECTION	Data should be collected using the elements as follows: Participation in social support of recovery activities is defined as attending self-help group meetings, attending religious/faith affiliated recovery or self help group meetings, attending meetings of organizations other than the organizations described above or interactions with family members and/or friends supportive of recovery. The reported measure will reflect differences in participation in the 30 days preceding admission to substance abuse treatment, and in the 30 days prior to discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique Statewide client ID.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data (e.g., TEDS, Addiction Severity Index (ASI), ASI-Lite, etc.).
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T6

State Description of Social Support of Recovery Data Collection (Form T6)

GOAL	To improve clients’ participation in social support of recovery activities to reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change in all clients receiving treatment who reported participation in one or more social and or recovery support activity at discharge.
STATE CONFORMANCE TO INTERIM STANDARD	States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T6 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify ___________________State collects admission and discharge data on social support of recovery that can be reported using definitions provided as follows: Participation in social support of recovery activities are defined as attending self-help, attending religious/faith affiliated recovery or self help groups, attending meetings of organizations other than the organizations described above or interactions with family members and/or friends supportive of recovery. YES____________ NO__________
EPISODE OF CARE	How is the admission/discharge basis defined for table T6 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________ State reported data using data other than admission and discharge data. YES____________ NO__________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T6 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment State reported data using administrative data. YES____________ NO__________
RECORD LINKINGDATA SOURCE(S)	Was the admission and discharge data linked for table T6 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.Source(s):
IF DATA IS UNAVAILABLEDATA ISSUES	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.Issues:
DATA PLANS IF DATA IS NOT AVAILABLEDATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing employment status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.State should provide time-framed plans for capturing social support of recovery data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

How to complete Form T7 – Retention

This form covers care the principal agency of the State purchased in the State expenditure period designated on Form 1.

Length of stay (LOS) is described by the date of first individual or group addiction counseling service to the date of last contact for each level of care (date at which no additional services are received within thirty days).

Use the column labeled Average to report the average (mean) length of stay.

Use the column labeled Median to report the median length of stay.

Use the column labeled Standard Deviation to report the standard deviation of the length of stay.

Refer to the Levels of Care as defined in the instructions for Form 7a and 12.

FORM T7: RETENTION

Length of Stay (in Days) of Clients Completing Treatment

Most recent State fiscal year for which data are available: _____________

STATE:

Length of Stay
level of care	average	median	STANDARD DEVIATION
DETOXIFICATION (24-HOUR CARE)
1. Hospital Inpatient
2. Free-Standing Residential
REHABILITATION/ RESIDENTIAL
3. Hospital Inpatient
4. Short-term (up to 30 days)
5. Long-term (over 30 days)
AMBULATORY (OUTPATIENT)
6. Outpatient
7. Intensive Outpatient
8. Detoxification
9. Opioid Replacement therapy Methadone

How to complete voluntary Form T7 – Retention

This form covers care the principal agency of the State purchased in the State expenditure period designated on Form 1.

Length of stay (LOS) is described by the date of first individual or group addiction counseling service to the date of last contact for each level of care (date at which no additional services are received within thirty days).

Use the column labeled Average to report the average (mean) length of stay.

Use the column labeled Median to report the median length of stay.

Use the column labeled Standard Deviation to report the standard deviation of the length of stay.

Refer to the Levels of Care as defined in the instructions for Form 7A.

SECTION IVb - BB

VOLUNTARY PREVENTION PERFORMANCE MEASURES

Data requested oin the following formstables:

FormTable P1 – NOMs Domain: Reduced Morbidity

Measure: 30-Day Use

FormTable P2 – NOMs Domain: Reduced Morbidity

Measure: Perception of Risk/Harm of Use

FormTable P3 – NOMs Domain: Reduced Morbidity

Measure: Age of First Use

FormTable P4 – NOMs Domain: Reduced Morbidity

Measure: Perception of Disapproval/Attitudes

FormTable P5 – NOMs Domain: Employment/Education

Measure: Perception of Workplace Policy

FormTable P6 – NOMs Domain: Employment/Education

Measure: ATOD-Related Suspensions and Expulsions

FormTable P7 – NOMs Domain: Employment/Education

Measure: Average Daily School Attendance Rate

FormTable P8 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol-Related Traffic Fatalities

FormTable P9 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol- and Drug-Related Arrests

FormTable P10 – NOMs Domain: Social Connectedness

Measure: Family Communications Around Drug and Alcohol Use

FormTable P11 – NOMs Domain: Retention

Measure: Youth Seeing, Reading, Watching, or Listening to a Prevention Message

FormTables P12a and P12b – Number of Persons Served by Age, Race, and Ethnicity

NOMs Domain: Access/Capacity

Measure: Persons Served by Age, Race, and Ethnicity

FormTable P13 – Number of Persons Served by Type of Intervention

NOMs Domain: Access/Capacity

Measure: Persons Served by Type of Intervention

Form Table P14 – Evidence-Based Programs and Strategies by Type of Intervention

NOMs Domain: Retention

NOMs Domain: Use of Evidence-Based Programs

Measure: Evidence-Based Programs and Strategies

FormTable P15 – Services Provided Within Cost Bands

NOMs Domain: Cost Effectiveness

Measure: Services Provided Within Cost Bands

Number of Persons Served (Prevention Form P1)

Number of Evidence-Based Programs, Practices, and Policies (Prevention Form P2)

Perception of Risk/Harm of and Unfavorable Attitudes Toward Substance Use by Those Under Age 21 (Prevention Form P3)

Use of Substances During the Past 30 Days (Prevention Form P4)

Introduction

The National Outcome Measures (NOMs) are a set of domains and measures that the Substance Abuse and Mental Health Services Administration (SAMHSA) will use to accomplish its vision and to meet all of its Federal reporting requirements, thus reducing burden and redundancy for grantees.

SAMHSA’s vision is a “Life in the Community for Everyone: Building Resilience and Facilitating Recovery.” Within this vision are three goals: accountability, capacity, and effectiveness for all Agency initiatives. The NOMs are SAMHSA’s means to address its accountability goal and performance-monitoring approach. Given the differing components of SAMHSA, the actual measures are slightly different across its three Centers—Center for Mental Health Services, Center for Substance Abuse Prevention (CSAP), and Center for Substance Abuse Treatment. The actual measures for each Center are posted on the SAMHSA Web site (http://www.nationaloutcomemeasures.samhsa.gov).

The BGAS NOMs Data Collection and Reporting Forms are to be completed as part of the State’s annual Substance Abuse Prevention and Treatment (SAPT) Block Grant application.

For the Federal fiscal year 2008 SAPT Block Grant application,

States must report their NOMs data for the compliance year based on Federal fiscal year 2005―October 1, 2004, through September 30, 2005.

For purposes of this section, unless otherwise noted, the term “State” refers to States, Territories, and Native American tribes that receive SAPT Block Grant funding.GENERAL INSTRUCTIONS

The following set of instructions and optional forms are available for States to complete on a voluntary basis. It is understood that, at the current time, not all States have the infrastructure in place that supports the reporting of such data. By participating on a voluntary basis, States can communicate their current capacity to report on the proposed Substance Abuse Prevention and Treatment (SAPT) Block Grant-supported program performance measures and will thus help inform future activities leading towards full implementation of the performance-based Block Grant program.

In completing these voluntary forms, please follow the guidelines below:

Include all participants who received services from prevention programs that received some or all of their funding from the SAPT Block Grant.

Relevant narrative information that applies to all reported data should be provided in a section preceding the reporting forms. If there is information relevant to only one reporting form, please include it in a section immediately preceding the relevant form and so indicate.

States are asked to report these data for the most recent State Fiscal Year (SFY) for which data are available at the time the application is submitted. In no case should the reporting year be earlier than the year for which the State reports SAPT Block Grant expenditures. Please insert the relevant SFY in the indicated area on each form.

Please provide as much data as is available for each form.

State applicants whose data collection systems are unable to report data in the format requested should contact their State Project Officer to discuss a suitable way to provide the data.

OPTION: If the State is using a standard statistical package that yields printouts containing the same information as the reporting forms, the State may attach the printouts in lieu of the reporting forms.

If possible, please provide the computer files and data tapes along with the application. This will allow for further analysis at the national level. Results of such analyses will be shared with the States and will be used in the development of future performance-based Block Grant program.

INSERT OVERALL NARRATIVE: State applicants should include a discussion of topics relevant to outcome reporting in general. This would include topics mentioned in instructions above as well as any additional information (e.g., data infrastructure needs) that the State deems important.

FormsTables P1 Through P11 – Information

A. Pre-populated Data

CSAP and the States have agreed that the State-level reporting requirement for the NOMs listed in FormsTables P1–P11 willmay be fulfilled through the use of extant data from sources including the National Survey on Drug Use and Health (NSDUH), the Fatality Analysis Reporting System (FARS) of the National Highway Traffic Safety Administration, the Uniform Crime Report (UCR) of the Federal Bureau of Investigation, and the National Center for Education Statistics (NCES) of the U.S. Department of Education. These pre-populated State-level NOMs will meet most of the State-level NOMs reporting requirements for the prevention portion of the SAPT Block Grant and Strategic Prevention Framework-State Incentive Grant funding. These data will be pre-populated into the Web BGAS and pre-populated data tables are also available though the CSAP State project officer (SPO).

NOMs Domain - Reduced Morbidity—Abstinence from Drug Use/Alcohol Use

FormTable P1: 30-Day Use

FormTable P2: Perception of Risk/Harm of Use

FormTable P3: Age of First Use

FormTable P4: Perception of Disapproval/Attitudes

NOMs Domain - Employment/Education

FormTable P5: Perception of Workplace Policy

FormTable P6: ATOD-Related Suspensions and Expulsions

FormTable P7: Average Daily School Attendance Rate

NOMs Domain - Crime and Criminal Justice

FormTable P8: Alcohol-Related Traffic Fatalities

FormTable P9: Alcohol- and Drug-Related Arrests

NOMs Domain - Social Connectedness

FormTable P10: Family Communications Around Drug and Alcohol Use

NOMs Domain - Retention

FormTable P11: Youth Seeing, Reading, Watching, or Listening to a Prevention Message

In this Block Grant application, States may choose to use the pre-populated data are automatically provided to fulfill the majority of their reporting requirements. States may submit requests for approval to use substitute data. for all or some of these measures. If State-generated substitute data are not submitted in this application, the prepopulation measures will be used.

Territories and Native American tribes for which there are no NSDUH, FARS, UCR, and/or NCES data will not be required to report on those measures at the State level, but will be encouraged to provide substitute data.

B. Application To Substitute Data

If a State wishes to substitute State-generated data for SAMHSA-provided national data, the State must request approval for the substitution through its CSAP State Project Officer (SPO).

The application for substitution must demonstrate at a minimum that:

• Data are at the State level.

• Data are collected, analyzed, and reported on an annual basis.

• Data are collected through a valid sample or true census (i.e., a convenience sample is not acceptable).

• Data protocol for data collection timeline, sample methodology, source (sample or census instrument), collection schedule, analysis, and reporting each meet reasonable standards of quality.

• Data will have to have been collected for 1 year before the date of the requested substitution in order to assess acceptability for substitution.

• Data shall be provided to SAMHSA/CSAP on an annual basis.

It should be noted that if a State agrees to use SAMHSA data this year as sources for the NOMs, this does not preclude the State in future years from requesting a substitution.

To substitute the pre-populated data with State-generated data, States must complete the following steps:

1. Complete an Application Form Tto Substitute Data (Prevention Attachment A). The form must be submitted to the SPO by Junely 15, 2007, who will submit it to SAMHSA/CSAP for review. CSAPSAMHSA will review the survey and the information provided, consider the validity issues compared to NSDUH, and provide a decision to the State by July 17, 2007. Note: For the purposes of the FY 2008 application only, each of the due dates are extended by 45 days. In the interim, pre-populated data will be used. within 30 days of receipt of the form.

2. If SAMHSA denies the substitution application, the State may appeal the decision. To appeal, the State will be asked to provide the following information using the Substitution Appeal Form (Prevention Attachment B):

   1. The specific measure that is being appealed

   2. The rationale for appealing SAMHSA’s decision

   3. A copy of the original substitution application

   4. Additional data/analysis to address concerns identified by SAMHSA

After receiving a denial, a State will have until August 1, 200730 days after receiving the denial to submit of the substitution to submit its an appeal. SAMHSA will then provide an appeal decision to the State by August 15, 2007within 30 days of receipt of the appeal.. Note: For the purposes of the FY 2008 application only, each of the due dates are extended by 45 days. In the interim, pre-populated data will be used.

3. After receiving the approval from SAMHSA, the State will include the substitute data in the Block Grant application. This entails two steps:

   1. Enter the substitute data in FormTable P1 Column D: Approved Substitute Data for the appropriate NOM.

   2. Complete the Approved Substitute Data Submission Form (Prevention Attachment C).

The deadline for full application submission to SAMHSA is October 1, 2007.

C. Supplemental Data

States may also wish to provide additional data related to the NOMs. An approved substitution is not required to provide this supplemental data. The data can be included in the Block Grant appendix. When describing the supplemental data, States should provide any relevant Web addresses (URLs) that provide links to specific State data sources.

Check here if you have submitted supplemental data or supporting documents in the BGAS appendix.

Provide a brief summary of the supplemental data included in the BGAS appendix:

D. Instructions for Completing FormsTables

Column A: Measure―The SAMSHA-defined measure for the domain listed.

Column B: Question/Response

• Source Survey Item: For FormsTables P1P5, P10, and P11, the source is the NSDUH. FFor TablesForms P6P9, other “archival” sources are identified. The specific language used for each item is provided.

• Response Option: The range of responses that are provided for the survey item.

• Outcome Reported: The specific responses that are included in the calculation provided for the item.

• Age: The age range for which the responses are provided. The Federal fiscal year (FY) 2008 application identifies FY 2005 as the baseline year for the NOMs data.

Column C: Pre-populated Data―Pre-populated data are provided; see description below.

Column D: Approved Substitute Data―States with pre-approval to submit substitute data will be able to enter the data for the item in this column. Note: If this column is left blank, the pre-populated data will be used.PREVENTION FORM P1

NUMBER OF PERSONS SERVED

Include all participants who received services from prevention programs that received some or all of their funding from the SAPT Block Grant.

Include participants who received services from programs at any time during the reporting year.

Report data for the most recent State Fiscal Year for which the data are available at the time the application is submitted. In no case should the reporting year be earlier than the year for which the State is reporting SAPT Block Grant expenditures in the application being submitted. Indicate the State Fiscal Year chosen for reporting in the appropriate place on the form.

FormTable P1 – NOMs Domain: Reduced Morbidity―Abstinence from Drug Use/Alcohol Use

Measure: 30-Day Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. 30-day Alcohol Use	Source Survey Item: NSDUH Questionnaire. “Think specifically about the past 30 days, that is, from [DATEFILL] through today. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used alcohol during the past 30 days.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
2. 30-day Cigarette Use	Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that is, since [DATEFILL], on how many days did you smoke part or all of a cigarette?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having smoked a cigarette during the past 30 days.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
3. 30-day Use of Other Tobacco Products	Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that is, since [DATEFILL], on how many days did you use [other tobacco products]†?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used a tobacco product other than cigarettes during the past 30 days, calculated by combining responses to questions about individual tobacco products (snuff, chewing tobacco, pipe tobacco).
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
4. 30-day Use of Marijuana	Source Survey Item: NSDUH Questionnaire: “Think specifically about the past 30 days, from [DATEFILL] up to and including today. During the past 30 days, on how many days did you use marijuana or hashish?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used marijuana or hashish during the past 30 days.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
5. 30-day Use of Illegal Drugs Other Than Marijuana	Source Survey Item: NSDUH Questionnaire: “Think specifically about the past 30 days, from [DATEFILL] up to and including today. During the past 30 days, on how many days did you use [any other illegal drug]‡?” Outcome Reported: Percent who reported having used illegal drugs other than marijuana or hashish during the past 30 days, calculated by combining responses to questions about individual drugs (heroine, cocaine, stimulants, hallucinogens, inhalants, prescription drugs used without doctors’ orders).
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)

^† NSDUH asks separate questions for each tobacco product. The number provided combines responses to all questions about tobacco products other than cigarettes.

^‡ NSDUH asks separate questions for each illegal drug. The number provided combines responses to all questions about illegal drugs other than marijuana or hashish.

PREVENTION FORM P1

NUMBER OF PERSONS SERVED

STATE:

REPORTING PERIOD: FROM TO

Persons served in Block Grant funded services include all persons served in prevention programs that receive all or part of their funding through the SAPT Block Grant.

Age	Total	Single Services	Recurring Services	Race/Ethnicity	Total	Single Services	Recurring Services	Gender	Total	Single Services	Recurring Services
0-4				American Indian/ Alaska Native				Female
5-11				Asian				Male
12-14				Black/African American
15-17				Native Hawaiian/ Other Pacific Islander
18-20				White
21-25				More Than One Race
26-44				Unknown
45-64				Total
65+				Not Hispanic Or Latino
				Hispanic Or Latino
Total				Total				Total

PREVENTION FORM P2

NUMBER OF EVIDENCE-BASED PROGRAMS, PRACTICES, AND POLICIES

Include all prevention programs that received some or all of their funding from the SAPT Block Grant.

Include programs that operated at any time during the reporting year.

Report data for the most recent State Fiscal Year for which the data are available at the time the application is submitted. In no case should the reporting year be earlier than the year for which the State is reporting SAPT Block Grant expenditures in the application being submitted. Indicate the State Fiscal Year chosen for reporting in the appropriate place on the form. The same reporting year is to be used for all of the voluntary performance measures forms.

On Prevention Form P2, evidence-based prevention programs are those programs or practices described in the National Registry of Evidence-based Programs and Practices (NREPP - 1 on Form P2), listed on other Federal agency lists of programs or practices of interest (2 on form P2), programs, practices, and policies that have been published in a peer reviewed journal and found to be effective (3 on Form P2) or other evidence-based programs, practices, and policies that do not fall in the above categories (4 on Form P2). Non-evidence-based programs, practices, and policies should also be listed (5 on Form P2). Provide descriptive material as requested on items 3, 4, and 5.

Utilizing the Institute of Medicine (IOM) preventive intervention categories (universal, selective, and indicated), specify the appropriate populations for which the program, practice, or policy was designed.

FormTable P2 – NOMs Domain: Reduced Morbidity―Abstinence from Drug Use/Alcohol Use

Measure: Perception of Risk/Harm of Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Perception of Risk From Alcohol	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
2. Perception of Risk From Cigarettes	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they smoke one or more packs of cigarettes per day?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
3. Perception of Risk From Marijuana	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they smoke marijuana once or twice a week?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)

PREVENTION FORM P2

NUMBER OF EVIDENCE-BASED PROGRAMS, PRACTICES, AND POLICIES

STATE:

REPORTING PERIOD: FROM TO

Programs include all prevention programs, practices, and policies that receive all or part of their funding through the SAPT Block Grant.

	Program Name and Source	Universal Populations	Selective Populations	Indicated Populations	Total
1.	List NREPP programs or practices below.
	Subtotal
2.	List programs or practices from lists recommended by other Federal agencies.
	Subtotal
3.	List peer-reviewed journal-evidenced programs, practices, and policies (attach journal citations).
	Subtotal
4.	List the names of other evidence-based programs, practices, and policies (attach source and type of evidence).
	Subtotal
TOTAL all evidence-based programs
5.	List the names and sources of non-evidence-based programs, practices, and policies (attach additional information on the program, practice, or policy).
	Subtotal
GRAND TOTAL all programs, practices, and policies
Percent Evidence-Based (sections 1–4 above)
Percent Non-Evidence-Based (section 5 above)

FormTable P3 – NOMs Domain: Reduced Morbidity―Abstinence from Drug Use/Alcohol Use

Measure: Age of First Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Age at First Use of Alcohol	Source Survey Item: NSDUH Questionnaire: “Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink.” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of alcohol.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
2. Age at First Use of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you smoked part or all of a cigarette?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of cigarettes.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
3. Age at First Use of Tobacco Products Other Than Cigarettes	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used [any other tobacco product]†?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of tobacco products other than cigarettes.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
4. Age at First Use of Marijuana or Hashish	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used marijuana or hashish?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of marijuana or hashish.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)
5. Age at First Use of Illegal Drugs Other Than Marijuana or Hashish	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used [other illegal drugs]‡?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of other illegal drugs.
	Ages 12–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)

^† The question was asked about each tobacco product separately, and the youngest age at first use was taken as the measure.

^‡ The question was asked about each drug in this category separately, and the youngest age at first use was taken as the measure.

PREVENTION FORM P3

PERCEPTION OF RISK/HARM OF and Unfavorable Attitudes Toward SUBSTANCE USE BY THOSE UNDER AGE 21

For Perception of Risk/Harm, SAMHSA has pre-populated the tables with State data from the National Household Survey on Drug Use and Health. States wishing to provide their own data on these items may attach the information as noted in # 6 and #7 of the Voluntary Prevention Measures General Instructions (p. 119).

Perception of Risk/Harm Items:

How much do people risk harming themselves physically or in other ways when they:

(1) Have four or five drinks of an alcoholic beverage nearly every day?

(2) Smoke one or more packs of cigarettes per day?

(3) Smoke marijuana regularly?

For Unfavorable Attitudes, SAMHSA has pre-populated the tables with State data from the National Household Survey on Drug Use and Health. States wishing to provide their own data on these items may attach the information as noted in # 6 and #7 of the Voluntary Prevention Measures General Instructions (p. 118).

Unfavorable Attitude Items:

How do you feel about someone your age:

(1) Having one or two drinks of an alcoholic beverage nearly everyday?

(2) Smoking one or more packs of cigarettes a day?

(3) Using marijuana once a month or more?

PREVENTION FORM P3

PERCEPTION OF RISK/HARM OF AND UNFAVORABLE ATTITUDES TOWARD SUBSTANCE USE BY THOSE UNDER AGE 21

STATE:

REPORTING PERIOD: FROM TO

For perception of risk/harm, report the number and percent of the State population who responded “slight risk,” “moderate risk,” or “great risk” (add the three categories).

For unfavorable attitudes, report the number and percent of the State population who responded “somewhat disapprove” or “strongly disapprove” (add the two categories).

Indicator	Drug	No. of Respondents	Percent of Respondents
Perception of Risk/Harm of Substance Use	Alcohol
	Cigarettes
	Marijuana
Unfavorable Attitudes Toward Substance Use	Alcohol
	Cigarettes
	Marijuana

FormTable P4 – NOMs Domain: Reduced Morbidity―Abstinence from Drug Use/Alcohol Use

Measure: Perception of Disapproval/Attitudes

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Disapproval of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age smoking one or more packs of cigarettes a day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2005 (Baseline)
2. Perception of Peer Disapproval of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How do you think your close friends would feel about you smoking one or more packs of cigarettes a day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent reporting that their friends would somewhat or strongly disapprove.
	Ages 12–17 - FFY 2005 (Baseline)
3. Disapproval of Using Marijuana Experimentally	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age trying marijuana or hashish once or twice?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2005 (Baseline)
4. Disapproval of Using Marijuana Regularly	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age using marijuana once a month or more?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2005 (Baseline)
5. Disapproval of Alcohol	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2005 (Baseline)

PREVENTION FORM P4

USE OF SUBSTANCES DURING THE PAST 30 DAYS

For this measure, SAMHSA has pre-populated the tables with State data from the National Household Survey on Drug Use and Health. States wishing to provide their own data on these items may attach the information as noted in # 6 and #7 of the Voluntary Prevention Measures General Instructions (p. 119).

Usage Items:

During the past 30 days, how many times have you used the following:

(1) Alcohol?

(2) Tobacco (cigarettes, snuff, cigars)?

(3) Marijuana?

(4) Cocaine/crack?

(5) Stimulants?

(6) Inhalants?

(7) Heroin?

PREVENTION FORM P4

USE OF SUBSTANCES DURING THE PAST 30 DAYS

STATE:

REPORTING PERIOD: FROM TO

Report the number and percent of the State population who responded having used at least one or more times in the past 30 days.

Drug		12-17 year olds	18-25 year olds	>26 year olds	Total
Alcohol	N
	%
Tobacco	N
	%
Marijuana	N
	%
Cocaine/Crack	N
	%
Stimulants	N
	%
Inhalants	N
	%
Heroin	N
	%

FormTable P5 – NOMs Domain: Employment/Education

Measure: Perception of Workplace Policy

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
Perception of Workplace Policy	Source Survey Item: NSDUH Questionnaire: “Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you?” [Response options: More likely, less likely, would make no difference] Outcome Reported: Percent reporting that they would be more likely to work for an employer conducting random drug and alcohol tests.
	Ages 15–17 - FFY 2005 (Baseline)
	Ages 18+ - FFY 2005 (Baseline)

FormTable P6 – NOMs Domain: Employment/Education

Measure: ATOD-Related Suspensions and Expulsions

In development.

FormTable P7 – NOMs Domain: Employment/Education

Measure: Average Daily School Attendance Rate

A. Measure	B. Source	C. Pre-populated Data	D. Approved Substitute Data
Average Daily School Attendance Rate	Source: National Center for Education Statistics, Common Core of Data: The National Public Education Finance Survey available for download at http://nces.ed.gov/ccd/stfis.asp Measure calculation: Average daily attendance (NCES defined) divided by total enrollment and multiplied by 100.
	FFY 2005 (Baseline)

FormTable P8 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol-Related Traffic Fatalities

A. Measure	B. Source	C. Pre-populated Data	D. Approved Substitute Data
Alcohol-Related Traffic Fatalities	Source: National Highway Traffic Safety Administration Fatality Analysis Reporting System Measure calculation: The number of alcohol-related traffic fatalities divided by the total number of traffic fatalities and multiplied by 100.
	FFY 2005 (Baseline)

FormTable P9 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol- and Drug-Related Arrests

A. Measure	B. Source	C. Pre-populated Data	D. Approved Substitute Data
Alcohol- and Drug-Related Arrests	Source: Federal Bureau of Investigation Uniform Crime Reports Measure calculation: The number of alcohol- and drug-related arrests divided by the total number of arrests and multiplied by 100.
	2005 (Baseline)

FormTable P10 – NOMs Domain: Social Connectedness

Measure: Family Communications Around Drug and Alcohol Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Family Communications Around Drug and Alcohol Use (Youth)	Source Survey Item: NSDUH Questionnaire: “Now think about the past 12 months, that is, from [DATEFILL] through today. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? By parents, we mean either your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.” [Response options: Yes, No] Outcome Reported: Percent reporting having talked with a parent.
	Ages 12–17 - FFY 2005 (Baseline)
2. Family Communications Around Drug and Alcohol Use (Parents of children aged 12–17)	Source Survey Item: NSDUH Questionnaire: “During the past 12 months, how many times have you talked with your child about the dangers or problems associated with the use of tobacco, alcohol, or other drugs?”† [Response options: 0 times, 1 to 2 times, a few times, many times] Outcome Reported: Percent of parents reporting that they have talked to their child.
	Ages 18+ - FFY 2005 (Baseline)

^† NSDUH does not ask this question of all sampled parents. It is a validation question posed to parents of 12- to 17-year-old survey respondents. Therefore, the responses are not representative of the population of parents in a State. The sample sizes are often too small for valid reporting.

FormTable P11 – NOMs Domain: Retention

Measure: Percentage of Youth Seeing, Reading, Watching, or Listening to a Prevention Message

Measure	Question/Response	Pre-populated Data	Approved Substitute Data
Exposure to Prevention Messages	Source Survey Item: NSDUH Questionnaire: “During the past 12 months, do you recall [hearing, reading, or watching an advertisement about the prevention of substance use]†?” Outcome Reported: Percent reporting having been exposed to prevention message.
	Ages 12–17 - FFY 2005 (Baseline)

^† This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within a specific context.

Forms P12a and P12b – Number of Persons Served by Age, Gender, Race, and Ethnicity

NOMs Domain: Access/Capacity

Measure: Number of Persons Served by Age, Gender, Race, and Ethnicity

The number of persons served by individual-based programs and strategies is reported in Table P12a and by population-based programs and strategies in Table P12b.

See Form 13 for definitions of activities, practices, procedures, processes, programs, and strategies.

Form P12a: Individual-Based Programs and Strategies—Number of Persons Served by Age, Gender, Race, and Ethnicity

Individual-based programs and strategies include practices and strategies with identifiable goals designed to change behavioral outcomes among a definable population or within a definable geographic area. These programs and strategies are provided to individuals or group of individuals who do not require treatment for substance abuse who receive the services over a period of time in a planned sequence of activities that are intended to inform, educate, develop skills, alter risk behaviors, or deliver services (e.g., a parent education group that meets once a week for 6 weeks).

• A key factor in recording the individual-based programs and strategies is whether or not individual-level information is recorded for the participants (e.g., gender, race/ethnicity, age). In most cases, participants in individual-based programs will complete pre- and post-test questionnaires.

• The individual-based program and strategy data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program or strategy will be recorded multiple times. For example, a young person may receive a prevention curriculum in his/her health class and also participate in an afterschool tutoring program. This individual would be reported twice. . Individual counts should be unduplicated within a program, but can be duplicated between programs.

• Data reported for individual-based programs should be based on actual counts―not on estimates of people served. MDS users: Individual-based programs that record participant numbers as “exact counts” would be reported in Table P12a.

• Examples of individual-based strategies include:

• School- and community-based curricula

• School- and community-based groups and organizations (e.g., SADD, 4-H, Peer Helpers)

• Alternative activities (e.g., afterschool programs)

• Community service activities

• Parent education classes and workshops

Instructions for completing Form P12a

Enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span calendar years, include the data for the reporting year only.

Category A. Age

Enter total number of participants for each age group listed.

If age is not known, enter the total in the Age Not Known subcategory.

Category B. Gender

Enter total number of male and female participants in the applicable rows.

If gender is not known, enter the total in the Gender Not Known subcategory.

Category C. Race

Using the Office of Management and Budget (OMB) designations as a guide, the following racial categories are to be reported:

• White

• Black or African American

• Native Hawaiian/Other Pacific Islander

• Asian

• American Indian/Alaskan Native

Enter total number of participants for each race listed in the applicable rows.

Participants who are more than one race should be added to the totals for each applicable race or to the total for the More Than One Race subcategory. They should not be included in the totals for both. Indicate in question 2 which way the State is reporting.

If race is not known or is other than those listed, enter the total in the Race Not Known or Other subcategory.

Category D. Ethnicity

Enter total number of Hispanic and Not Hispanic participants in the applicable rows.

Question 1: Describe the data collection system you used to collect the NOMs data (e.g., MDS, DbB, KIT Solutions, manual process).

Question 2: Describe how your State’s data collection and reporting processes record a participant’s race, specifically for participants who are more than one race.

Indicate whether the State added those participants to the number for each applicable racial category or whether the State added all those participants to the More Than One Race subcategory.

Form P12a – Individual-Based Programs and Strategies—Number of
Persons Served by Age, Gender, Race, and Ethnicity

Category	Total
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino

Form P12b: Population-Based Programs and Strategies—Number of Persons Served by Age, Gender, Race, and Ethnicity

Population-based programs and strategies include planned and deliberate goal-oriented practices, procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps subject to monitoring and modification. Included within this definition are environmental strategies (which establish or change written and unwritten community standards, codes, laws, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population), one-time or single events (such as a health fair, a school assembly, or the distribution of material), and other activities intended to impact a broad population. The goal is to record the numbers of people impacted by the program or strategy.

• Data reported for population-based programs and strategies should be based on actual numbers (if known) or estimates of people served. For programs and strategies that reach an identifiable population (e.g., an entire county, city, or State, or a targeted age range), it is permissible to use U.S. Census Bureau data (if available) to estimate the number of persons served.

• The population-based program data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program will be recorded multiple times. For example, a young person may attend a high school presentation on substance abuse one day and attend a health fair the next. This individual would be reported twice.

• MDS users: Participants recorded as “estimated counts” could be recorded as population-based programs and strategies.

• Examples of how to record population-based programs and strategies include:

• Brochure dissemination―number of people receiving the brochure

• Radio/TV talk show expert―number of people listening to or viewing the show

• Health fair―number of people attending the fair

• School assembly―number of people attending the assembly

• Public service announcement (PSA)―number of people listening to or viewing the PSA

• Coalition building―number of people in the coalition

• Developing community policies (e.g., restrictions on advertising)―number of people in the community

• Planning, managing, and coordinating efforts to effect positive community change―number of people involved in the planning effort

• Media campaign―number of people living in the “community” impacted by the media campaign

• Other environmental strategies, including media advocacy, keg registration, ID card enforcement, warning labels, server trainings―number of people impacted by the strategy

Instructions for completing Form P12b

Enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include numbers from the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span calendar years, include the data for the reporting year only.

Category A. Age

Enter total number served for each age group listed.

If age is not known, enter the total in the Age Not Known subcategory.

Category B. Gender

Enter total number of males and females served in the applicable rows.

If gender is not known, enter the total in the Gender Not Known subcategory.

Race

Using the Office of Management and Budget (OMB) designations as a guide, the following racial categories are to be reported:

• White

• Black or African American

• Native Hawaiian/Other Pacific Islander

• Asian

• American Indian/Alaskan Native

Enter total number served for each race listed in the applicable rows. Enter number of persons served identified as more than one race in the applicable row. Do not enter numbers for those persons in each applicable racial subcategory.

If race is not known or is other than those listed, enter the total in the Race Not Known or Other subcategory.

Category D. Ethnicity

Enter total number of Hispanic and Not Hispanic participants in the applicable rows.

Table P12b – Population-Based Programs and Strategies—Number of
Persons Served by Age, Gender, Race, and Ethnicity

Category	Total
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino

FormsTables P12a and P12b – Number of Persons Served by Age, Race, and Ethnicity

NOMs Domain: Access/Capacity

Measure: Number of Persons Served by Age, Race, and Ethnicity

The number of persons served by individual-based programs and strategies is reported in Table P12a and by population-based programs and strategies in Table P12b.

FormTable P12a: Number of Persons Served by Age, Race, and Ethnicity―Individual-Based Programs and Strategies

Individual-based programs and strategies include practices and strategies with identifiable goals designed to change behavioral outcomes among a definable population or within a definable geographic area. These programs and strategies are provided to individuals or group of individuals who do not require treatment for substance abuse who receive the services over a period of time in a planned sequence of activities that are intended to inform, educate, develop skills, alter risk behaviors, or deliver services (e.g., a parent education group that meets once a week for 6 weeks).

A key factor in recording the individual-based programs and strategies is whether or not individual-level information is recorded for the participants (e.g., gender, race/ethnicity, age). In most cases, participants in individual-based programs will complete pre- and post-test questionnaires.

The individual-based program and strategy data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program or strategy will be recorded multiple times. For example, a young person may receive a prevention curriculum in his/her health class and also participate in an afterschool tutoring program. This individual would be reported twice. Individual counts should be unduplicated within a program, but can be duplicated between programs.

• Data reported for individual-based programs should be based on actual counts―not on estimates of people served. MDS users: Individual-based programs that record participant numbers as “exact counts” would be reported in FormTable P12a.

• Examples of individual-based strategies include:

• School- and community-based curricula

• School- and community-based groups and organizations (e.g., SADD, 4-H, Peer Helpers)

• Alternative activities (e.g., afterschool programs)

• Community service activities

• Parent education classes and workshops

Instructions for completing FormTable P12a

Enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the fiscal year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span the fiscal year, include the data for each year in which the program or strategy operates.

Column A: Individual-Based Programs and Strategies

Enter number of males and females and total for each age group (rows 110) and the total (row 11).

If the number of males and females is not known, enter the number for each age group (rows 111) in the Total column.

If ages are not known, enter the total of males and females in the Total row (row 11).

Columns B–F: Race

Using the Office of Management and Budget (OMB) designations as a guide, the following racial categories are to be reported:

Column B: White

Column C: Black or African American

Column D: Native Hawaiian/Other Pacific Islander

Column E: Asian

Column F: American Indian/Alaskan Native

Enter number of males and females and total for each age and race (rows 110) and the total (row 11).

If the number of males and females is not known, enter the number for each age group (rows 111) in the Total column.

If ages are not known, enter the total of males and females in the Total row (row 11).

Note: The numbers entered in the race categories may add up to a number greater than the total number served reported in column A. This situation will result when an individual reports more than one race. For example, if an individual is both Black and Asian he/she will be reported as both Black and Asian.

Columns G and H: Ethnicity

Enter number of male and females and total of Hispanic and Not Hispanic for each age (rows 110) and the total (row 11).

If the number of males and females is not known, enter the number for each age group (rows 111) in the Total column.

If ages are not known, enter the total of males and females in the Total row (row 11).

Column I: Race Unknown or Other (not required by OMB)

Enter number of male and females and total for each age and listed as “Race Unknown or Other” (rows 1–10) and the total (row 11).

If the number of males and females is not known, enter the number for each age group (rows 111) in the Total column.

If ages are not known, enter the total of males and females in the Total row (row 11).

Column J: More Than One Race (not required by OMB)

Enter number of male and females and total for each age and listed as “More than one race” (rows 110) and the total (row 11).

If the number of males and females is not known, enter the number for each age group (rows 111) in the Total column.

If ages are not known, enter the total of males and females in the Total row (row 11).

Question 1: Describe the data collection system you used to collect the NOMs data (e.g., MDS, DbB, KIT Solutions, manual process).

Question 2: Describe how your State data collection and reporting processes record an individual’s race. Specifically, describe how data about individuals who are more than one race are reported in columns BF. For example, if an individual is both Black and Asian, is the individual recorded in columns C and E as both Black and Asian; either Black or Asian; neither Black nor Asian; or in some other manner?

Table Form P12a – Number of Persons Served by Age, Race, and Ethnicity

Individual-Based Programs and Strategies

Age

Race

Ethnicity

I. Race Unknown or Other

J. More Than One Race

Gender

B White

C Black or African American

D Native Hawaiian/ Other Pacific Islander

E Asian

F American Indian/ Alaska Native

G Not Hispanic or Latino

H Hispanic or Latino

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

Male

Female

Total

1. 0–4

2. 5–11

3. 12–14

4. 15–17

6. 18–20

7. 21–24

8. 25–44

9. 45–64

10. 65 and Over

11. Total

FormTable P12b: Number of Persons Served by Age, Race, and Ethnicity―Population-Based Programs and Strategies

Population-based programs and strategies include planned and deliberate goal-oriented practices, procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps subject to monitoring and modification. Included within this definition are environmental strategies (which establish or change written and unwritten community standards, codes, laws, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population) and one-time or single events (such as a health fair, a school assembly, or the distribution of material). The goal is to record the numbers of people impacted by the program or strategy.

Data reported for population-based programs and strategies should be based on actual numbers (if known) or estimates of people served. For programs and strategies that reach an identifiable population (e.g., an entire county, city, or State, or a targeted age range), it is permissible to use U.S. Census Bureau data (if available) to estimate the number of persons served.

The population-based program data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program will be recorded multiple times. For example, a young person may attend a high school presentation on substance abuse one day and attend a health fair the next. This individual would be reported twice.

MDS users: Participants recorded as “estimated counts” could be recorded as population-based programs and strategies.

• Examples of how to record population-based programs and strategies include:

• Brochure dissemination―number of people receiving the brochure

• Radio/TV talk show expert―number of people listening to or viewing the show

• Health fair―number of people attending the fair

• School assembly―number of people attending the assembly

• Public service announcement (PSA)―number of people listening to or viewing the PSA

• Coalition building―number of people in the coalition

• Developing community policies (e.g., restrictions on advertising)―number of people in the community

• Planning, managing, and coordinating efforts to effect positive community change―number of people involved in the planning effort

• Media campaign―number of people living in the “community” impacted by the media campaign

• Other environmental strategies, including media advocacy, keg registration, ID card enforcement, warning labels, server trainings―number of people impacted by the strategy

• Instructions for completing FormTable P12b

Enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the fiscal year. Include numbers from the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span the fiscal year, include the data for each year in which the program or strategy is funded.

Total Number of Persons Served

Column A: Enter the total number of persons served for each age group in rows 110. Enter the total of rows 1–10 in row 11.

Gender

Column B: Enter number of males in row 1.

Column C: Enter number of females in row 1.

Race

Using the OMB designations as a guide, the following racial categories are to be reported:

Column D: White

Column E: Black or African American

Column F: Native Hawaiian/Other Pacific Islander

Column G: Asian

Column H: American Indian/Alaskan Native

Ethnicity

Column I: Enter number of persons who are Not Hispanic or Latino in row 1.

Column J: Enter the number of persons who are Hispanic or Latino in row 1.

Race Unknown or Other (not required by OMB)

Column K: Enter number persons identified as “Race Unknown or Other” in row 1.

More Than One Race (not required by OMB)

Column L: Enter number of persons identified as “More than one race” in row 1.

FormTable P12b – Number of Persons Served by Age, Race, and Ethnicity

Population-Based Programs and Strategies

Age

A. Total Number of Persons Served

Gender

Race

Ethnicity

K. Race Unknown or Other

L. More Than One Race

B. Male

C. Female

D. White

E. Black or African American

F. Native Hawaiian/ Other Pacific Islander

G. Asian

H. American Indian/ Alaska Native

I. Not Hispanic or Latino

J. Hispanic or Latino

1. 0–4

2. 5–11

3. 12–14

4. 15–17

6. 18–20

7. 21–24

8. 25–44

9. 45–64

10. 65 and Over

11. Total

Optional FormTable P13 – Number of Persons Served by Type of Intervention

NOMs Domain: Access/Capacity

Measure: Number of Persons Served by Type of Intervention

Interventions include activities, practices, procedures, processes, programs, services, and strategies (as defined below):

Activity

• A specified pursuit in which an organization or person partakes to remedy a specific problem or issue; includes level of intensity and frequency (e.g., parent training classes on underage drinking prevention strategies).

• A process or procedure intended to stimulate learning through actual experience.

Practices

Repeated performance of an activity or strategy to perfect a skill or an outcome (e.g., Best practices - Strategies, activities, approaches, or programs shown through research and evaluation to be effective at preventing and/or delaying substance use and abuse; Exemplary Practices - Those which long-term empirical research and evaluation have documented to be effective in reducing substance use and abuse; Promising Practices - Strategies, activities, approaches, or programs for which the level of certainty from available evidence is too low to support generalized conclusions, but for which there is some empirical basis for predicting that further research could support such conclusions).

Procedures

A series of steps taken to accomplish an end.

Processes

A series of actions, changes, or functions bringing about a results, i.e., strengthening or enhancing individual (community, family, etc.) in knowledge and skills that are essential in healthy behaviors.

Programs

A system or coordinated set of activities, approaches, strategies, services, opportunities, practices or projects, designed to influence changes in behaviors, knowledge, attitudes, organizational practices and policies that are designed to achieve specific objectives over time (e.g., creating healthy people and healthy environments).

Services

Performance of work or duties or provision of space and equipment helpful to achieve health or wellness.

Strategy

A plan of action (activities – e.g., policy changes, practices, or approaches), that can be implemented to achieve specific objectives and for which a strong evidence base may or may not exist.

IIntervention types are defined as:

• Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Row 1—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Universal Indirect. Row 2— Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.Interventions support population-based programs and strategies, including the provision of information. See the definition of population-based activities provided below for a complete description of these activities.

• Selective. Row 3―Activities targeted to individuals or a subgroup of a population whose risk of developing a disorder is significantly higher than average.

• Indicated. Row 4― Activities targeted to individuals, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Totals. Row 5—Insert the totals for each column.

Instructions for completing FormTable P13

For each of the intervention types defined above, enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the fiscal year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span the fiscal year, include the data for each year in which the program or strategy is funded. When a program involves multiple strategies (e.g., Project Northland) report as one program in either the individual-based programs and strategies or in the population-based programs and strategies.

Column A: Individual-Based Programs and Strategies―Include practices and strategies with identifiable goals designed to change behavioral outcomes among a definable population or within a definable geographic area. Individual-based programs and strategies are provided to individuals or group of individuals who receive the services over a period of time in a planned sequence of activities that are intended to inform, educate, develop skills, alter risk behaviors, or provide direct services (e.g., a parent education group that meets once a week for 6 weeks).

• A key factor in recording the individual-based programs and strategies is whether or not individual-level information is recorded for the participants (e.g., gender, race/ethnicity, age). In most cases, participants in individual-based programs will complete pre- and post-test questionnaires.

• The individual-based program and strategy data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program or strategy will be recorded multiple times. For example, a young person may receive a prevention curriculum in his/her health class and also participate in an afterschool tutoring program. This individual would be reported twice. Individual counts should be unduplicated within a program, but can be duplicated between programs.

• Data reported for individual-based programs should be based on actual counts―not on estimates of people served. MDS users: Participants recorded as “exact counts” could be recorded as individual-based programs and strategies.

• Examples of individual-based strategies include the following:

• School- and community-based curricula

• School- and community-based groups and organizations (e.g., SADD, 4-H, Peer Helpers)

• Alternative activities (e.g., afterschool programs, drop-in centers)

• Community service activities

• Parent education classes and workshops

• Participants in server training classes

Column B: Population-Based Programs and Strategies―Include planned and deliberate goal- oriented practices, procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps subject to monitoring and modification. Included within this definition are environmental strategies (which establish or change written and unwritten community standards, codes, laws, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population.), one-time or single events (such as a health fair, a school assembly, or the distribution of material), and other activities intended to impact a broad population. The goal is to record the numbers of people impacted by the program or strategy.

• Data reported for population-based programs and strategies should be based on actual numbers (if known) or estimates of people served. For programs and strategies that reach an identifiable population (e.g., an entire county, city, or State), it is permissible to use U.S. Census Bureau data (if available) to estimate the number of persons served.

• The population-based program data may be provided as a duplicate count; that is, an individual who participates in more than one individual-population-based program will be recorded multiple times. For example, a young person may attend a high school presentation on substance abuse one day and attend a health fair the next. This individual would be reported twice. When a strategy is used with the same population (e.g., weekly radio shows) the goal would be to provide annual unduplicated counts within that strategy.

• MDS users: Participants recorded as “estimated counts” could be recorded as population-based programs and strategies.

• Examples of how to record population-based programs and strategies include:

• Brochure dissemination―number of people receiving the brochure

• Radio/TV talk show expert―number of people listening to or viewing the show

• Health fair―number of people attending the fair

• School assembly―number of people attending the assembly

• PSAs―number of people listening to or viewing the PSA

• Coalition building―number of people in the coalition

• Developing community policies (e.g., restrictions on advertising)―number of people in the community

• Planning, managing, and coordinating efforts to effect positive community change―number of people involved in the planning effort

• Media campaign―number of people living in the “community” impacted by the media campaign

• Other environmental strategies, including media advocacy, keg registration, ID card enforcement, warning labels, server trainings (number of people impacted by the strategy)

FormTable P13 – Number of Persons Served by Type of Intervention

Intervention Type	Number of Persons Served by Individual- or Population-Based Program or Strategy
	A. Individual-Based Programs and Strategies	B. Population-Based Programs and Strategies
1. Universal Direct		N/A
2. Universal Indirect	N/A
3. Selective		N/A
4. Indicated		N/A
5. Total

FormTable P14 – Evidence-Based Programs and Strategies by Type of Intervention

NOMs Domain: Retention

NOMs Domain: Evidence-Based Programs and Strategies

Measure: Number of Evidence-Based Programs and Strategies

Definition of Evidence-Based Programs and Strategies: The guidance document for the Strategic Prevention Framework State Incentive Grant, Identifying and Selecting Evidence-based Interventions, provides the following definition for evidence-based programs:

• Inclusion in a Federal List or Registry of evidence-based interventions

• Being reported (with positive effects) in a peer-reviewed journal

• Documentation of effectiveness based on the following guidelines:

• Guideline 1: The intervention is based on a solid theory or theoretical perspective that has validated research, and

• Guideline 2: The intervention is supported by a documented body of knowledge―a converging of empirical evidence of effectiveness―generated from similar or related interventions that indicate effectiveness, and

• Guideline 3: The intervention is judged by informed experts to be effective (i.e., reflects and documents consensus among informed experts based on their knowledge that combines theory, research, and practice experience). “Informed experts” may include key community prevention leaders, and elders or other respected leaders within indigenous cultures.

1. Describe the process the State will use to implement the guidelines included in the above definition.

2. Describe how the State collected data on the number of programs and strategies. What is the source of the data?

Instructions for completing Form Table P14

Enter the number of evidence-based programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the fiscal year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span the fiscal year, include the data for each year in which the program or strategy operates.

Intervention types are defined as:

• Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Column A—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Universal Indirect. Column B— Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Interventions support population-based programs and strategies, including the provision of information and technical assistance. See the definition of population-based activities provided below for a complete description of these activities.

• Column C—Insert the total for each row of the number in columns A and B. Note: If data collected do not differentiate by Universal Direct and Universal Indirect, enter the total number of Universal Programs in column C.

• Selective. Column D—Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated. Column E— Activities targeted to individuals, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Totals. Column F―Totals for columns C, D, and E.

For each intervention type listed above, record the following information:

• Row 1: Number of evidence-based programs and strategies. Enter the number of evidence-based programs and strategies:

• Report the number of evidence-based programs and strategies funded by SAPT Block Grant funds. For example, if a State funds 10 providers and each provider implements 3 evidence-based programs and strategies, and each program is implemented 3 times, the State would report “90”the State would report “30” as the number of evidence-based programs and strategies. Do not report the number of implementations of the evidence-based programs and strategies by the 10 providers.

• Include all evidence-based programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the fiscal year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding.

• For programs and strategies lasting longer than a year or that span the fiscal year, include the data in each year in which the program or strategy operates.

• Row 2: Total number of programs and strategies. Enter the total number of programs and strategies:

• Report the number of all programs and strategies funded by SAPT Block Grant funds. For example, if a State funds 10 providers and each provider implement 5 programs and strategies, and each program is implemented 3 times, the State would report “150”the State would report “50” as the number of programs and strategies. Do not report the number of implementations of the programs and strategies by the 10 providers.

• Report the number of all programs and strategies funded wholly or in part by SAPT Block Grant funds during the fiscal year. Include evidence-based programs and strategies in the total. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding.

• For programs and strategies lasting longer than a year or that span the fiscal year, include the data in each year in which the program or strategy operates.

• Row 3: Percent of evidence-based programs and strategies. Determine this by the following formula:

Percent of evidence-based programs and strategies:

= Number of evidence-based programs and strategies x 100

Total number of programs and strategies

FormTable P14 – Number of Evidence-Based Programs and Strategies by Type of Intervention

	Number of Programs and Strategies by Type of Intervention
	A. Universal Direct	B. Universal Indirect	C. Universal Total	D. Selective	E. Indicated	F. Total
1. Number of Evidence-Based Programs and Strategies Funded
2. Total number of Programs and Strategies Funded
3. Percent of Evidence-Based Programs and Strategies

FormTable P15 – Services Provided Within Cost Bands

Form P15 – Services Provided Within Cost Bands

NOMs Domain: Cost Effectiveness

Measure: Services Provided Within Cost Bands

Information About Cost Bands

Cost band information collected from Block Grant subrecipients in calendar year 2005 should be reported in the aggregate in Form P15. Since this is a transition year, States who have not collected this information by calendar year may, for this years’ application only, report by State Fiscal Year or an alternative time frame and indicate what timeframe was used.

What is a cost band?

• A cost band is the range of participant costs across multiple programs and strategies.

• Costs are computed on a per-person basis.

• The range of program costs is distributed in percentiles.

• The cost band NOM will report the percentage of programs whose costs per participant fall within the 25th and 75th percentiles of the cost-band distribution.

• Cost bands must be developed for each type of prevention intervention or Institute of Medicine (IOM) category (Universal, Selective, Indicated).

• The cost band data will allow CSAP to meet its Performance Assessment Rating Tool (PART) and NOMs reporting requirements. In addition, this documentation of costs for prevention services is intended to benefit the grantees.

How were the CSAP cost bands developed?

• Costs per person receiving a service provided by program or strategy were derived from the literature and grantee reports for each IOM intervention type.

• Because the cost information collected was not standardized (e.g., different time periods were used by different sources), CSAP will revise the cost bands for each program based on the data collected in the next 2 years.

What are the baseline cost bands?

As part of its reporting requirements under PART and NOMS, CSAP is required to document the increase in the number of services provided within cost bands. The provisional 2005 baseline is that the cost of 50% of services provided fall within the dollar values specified for each program type in the table below. The following table displays the cost bands adjusted to reflect 2005 dollars.

2005 Percentiles	IOM Intervention Type
	Universal Direct	Universal Indirect	Selective	Indicated
25th Percentile	$58.01	$1.05	$151.88	$510.47
75th Percentile	$693.98	$82.26	$6,409.29	$4,888.44

Instructions for completing FormTable P15

The information provided in FormTable P15 is based on the aggregated data collected by States from their Block Grant subrecipients. Prevention Attachment D: 2005 Block Grant Subrecipient Cost Band Worksheet provides a data collection tool for States to collect cost band information from each of their subrecipients.

Column A: Number of Programs. Add the number of programs reported by all subrecipients in column 1 of the Subrecipient Cost Band Summary (Prevention Attachment D, Subrecipient Table 2) for each program type.

Column B: Number of Programs Falling Within Cost Bands. Add the number of programs falling within cost bands in column 2 of the Subrecipient Cost Band Summary (Prevention Attachment D, Subrecipient Table 2) for each program type.

Column C: Percent of Programs Falling Within Cost Bands. Calculate the percentage of programs falling within cost bands by dividing column B of FormTable P15 (number of programs falling within cost bands) by column A (number of programs) of FormTable P15.

Types of Interventions

Enter the above information for each of the following types of interventions:

• Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Row 1— Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class).

• Universal Indirect. Row 2— Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Interventions support population-based programs and strategies, including the provision of information and technical assistance. See the definition of population-based activities provided below for a complete description of these activities.

• Row 3—Subtotal for Universal Programs.

• Selective. Row 4—Activities targeted to individuals or a subgroup of a population whose risk of developing a disorder is significantly higher than average.

• Indicated. Row 5— Activities targeted to individuals, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Totals. Row 6—Insert the totals for each column.

FormTable P15 – Services Provided Within Cost Bands

Type of Intervention	A. Number of Programs and Strategies	B. Number of Programs and Strategies Falling Within Cost Bands	C. Percent of Programs and Strategies Falling Within Cost Bands
1. Universal Direct Programs and Strategies
2. Universal Indirect Programs and Strategies
3. Subtotal Universal Programs
4. Selective Programs and Strategies
5. Indicated programs and Strategies
6. Total All Programs

Prevention Attachment A:

Application Form To Substitute Data

1. Contact Information

State/Territory/tribe:

Name of the applicant (first and last name):

Title:

 Mr.  Ms.  Dr.  Other _____________________

State position:

Organization:

Department:

Mailing address:

E-mail address:

Telephone: Fax:

2. Measure Labels

Label of the National Outcome Measure (NOM) being replaced:

Label of the substituted measure (if not identical to the NOM):

3. Narrative Justification

Provide a brief description of the reasons for the substitution. Continue on the back of the page if necessary.

4. Data Source for Substituted Measure

Name of the agency or organization responsible for data collection:

Name of contact person at data collection agency/organization (first and last name):

E-mail address:

Telephone:

Most recent year for which data are available:

Is data collection repeated every year?

 Yes  No (Indicate frequency of data collection.)______________________

Are trend data available?

 Yes (Indicate start year of trend data.)_________________________  No

What is the mode of data collection?  Census  Survey (Please complete item 5.)

 Other (Please describe.)

5. Survey Description

(Skip if mode of data collection is not a survey.)

The following questions refer to the most recent implementation of the survey.

Date of data collection:

Sample size:

Sampling ratio (sample size divided by the size of the target population):

What type of sampling strategy was used to select respondents? (Please check one.)

• Convenience sample (no statistical sampling techniques were used)

• Probability sample (statistical sampling techniques were used)

The following four questions apply to probability samples only.

If the sample is stratified, please identify each stratum:

If cluster sampling was used, please identify the clustering unit(s):

If a multistage design was used, please identify the unit sampled at each stage:

Potential sources of bias in the sample design:

The following questions apply to all surveys.

Method of administration:  Mail-in  Telephone  Face-to-face

 School-based: self-administered  Self-administered: survey site other than a school

 Other (Please specify.)

Was the interview computer-assisted?  Yes  No

Name of the survey instrument:

What was the survey response rate (i.e., multiply the number who took the survey/original sample size by 100)?

Were there validity and reliability tests of the survey items constituting the substitute measure?

 No

 Yes (Please describe reliability/validity study/studies.)

Are there any published validity/reliability studies for this instrument?

 No

 Yes (Please provide bibliographic information.)

6. Dataset Submission Information

Name of the data file(s) being submitted:

Description of data file(s) (Include format and size.):

For each data file, describe the content of the data records (e.g., “Each record contains all of the information for a single individual.”):

Names of documentation files:

Description of documentation file(s):

Total number of files being submitted:

Instructions for Completing the Substitution Application

Introduction

This form should be completed if a State wishes to substitute data collected through a State effort for the prepopulated National Outcome Measures (NOMs) on the BGAS NOMs Data Collection and Reporting Forms. If the grantee is requesting substitutions for more than one NOM, a separate form one application should be completed for all each NOMs for which a substitution is requested. The following section contains instructions, examples, and clarifications for completing the form.

Instructions for Completing the Form

Item 1

Provide contact information for the person responsible for this application. The person should be able to answer any further questions that may arise about the requested measure substitution and the source of data for the substituted measure.

Item 2

Label of the National Outcome Measure (NOM) being replaced:

Fill in the label of the NOM for which the substitution is requested.

Examples:

“30-Day Use of Marijuana”

“Alcohol-Related Arrests”

Label of the substituted measure:

If the substituted measure has a label that is different from the NOM, fill in the label.

Examples:

“Past Month Use of Marijuana”

“Alcohol-Related Offenses”

If the substituted measure has a label identical to the NOM, leave the space blank.

Item 3

Provide reasons why the proposed substitution will be a better representation of the State’s data on this measure. For example, if the State has an ongoing needs-assessment survey including variables comparable to this NOM, a possible reason for the substitution may be that the sample size of the State survey is larger than the number of respondents from the State selected into the annual National Survey of Drug Use and Health (NSDUH) that is used to prepopulate the form.

Item 4

Name and contact information of the agency or organization responsible for data collection:

For example, if the data source is a needs assessment survey conducted by a local university, provide the name of the university, the academic unit responsible for the survey’s administration, and contact information for the person within that academic unit who is in charge of the survey’s administration. This person should be capable of answering questions about the data collection procedure.

Most recent year for which data are available:

For survey data, enter the date or date range for the most recent survey implementation. For archival data such as school attendance or arrest rates, enter the Federal fiscal year (or school year) for the most recent data available.

Is data collection repeated every year?

Select “Yes” if the data source provides data for every year. If data are not available annually, indicate the frequency with which new data are released (e.g., “every other year on even years”).

Are trend data available?

This question is about the availability of past data. If the data source has been releasing data going back several years, select “Yes” and indicate the date when this source first started releasing data.

What is the mode of data collection?

A census collects data from every individual in the target population. A survey collects data from a selected group of individuals in the target population. A typical example of a data source other than a census or a survey is the records kept by an organization or a State agency such as the State Department of Education or Department of Public Health.

Item 5

This section should be completed only if the data source is a survey.

Date of data collection:

Fill in the date or the range of dates of the most recent survey administration.

Sample size:

Fill in the number of individuals originally selected into the sample, not the number of individuals for whom a completed survey form exists.

Sampling Ratio (Sample size divided by the size of the target population):

For the sample size, use the number originally selected into the sample.

If the sample is stratified, please identify each stratum:

A stratified sample is one where the target population is first divided into groups, and then individuals are selected from each group. This is usually done to ensure that all groups of interest are represented in the sample. For example, the target population could be divided into racial groups and a sample drawn from each group. In this case, the sample would be “stratified by race” and the strata used would be each racial categorization used (e.g., “White, Black, Asian, Other”).

If cluster sampling was used, please identify the clustering unit(s):

Cluster sampling is when a sample is drawn first among clusters of individuals (such as a school or a city block). Once a cluster is selected, either all of the individuals in the cluster are surveyed or a further selection is made among the individuals in the selected clusters.

If a multistage design was used, please identify the unit sampled at each stage:

Multistage sampling usually accompanies clustering. The sampling is done in several stages. First, clusters are selected from a population of all clusters. Then, either individuals or clusters of individuals are selected from the first-stage clusters. For example, several school districts could be selected from the entire pool of districts in the State (first stage). In each selected district, several schools could be selected from the entire pool of schools (second stage). In each sampled school, several students could be selected to take the survey (third stage).

Potential sources of bias in the sample design:

Sources of bias are factors that may affect the representativeness of the sampling design. For example, of households are selected from the phone directory, households without a phone will not be represented in the sample, resulting in biased estimates of variables such as income or type of community. If a large proportion of the sampled individuals refuse to be surveyed, the survey results will over-represent those who are interested in the survey topic.

Method of administration:

A mail-in survey is one where the sampled individuals receive the survey form in the mail, complete the form and mail it back to the administrators. A telephone survey is one where an interviewer interviews the sampled individual on the phone. A face-to-face survey is one where the interviewer contacts and interviews the sampled individual in person. A school-based survey is conducted in schools. Survey forms are handed out to sampled students who complete them (usually in a class period or special assembly) and turn them in. A self-administered survey is one where there is no interviewer. Respondents complete the survey form themselves. Examples of other methods of administration are survey forms sent via e-mail or posted on a wWeb site.

Was the interview computer-assisted?

A computer-assisted survey is one where the survey form is on a computer instead of a paper form. These can be either self-administered (the respondent sits at the computer and responds to questions appearing on the screen) or conducted through an interviewer who poses the questions to the respondent and enters the responses directly into the computer.

Name of the survey instrument:

Most survey instruments have a title. This can be a special-purpose local survey, for example, “The Anytown County Needs Assessment Survey” or a standardized and widely used instrument such as The Youth Risk Behavior Survey (or YRBSS).

Were there validity and reliability tests of the survey items constituting the substitute measure?

Survey instruments are first tested in pilot studies or cognitive tests to evaluate the clarity of wording, the comprehension level of typical members of the target population, the ability of the questions to provide valid data on the concepts being measured, and the internal consistency of multi-item scales. If such testing was conducted prior to the fielding of the survey, briefly describe the study, including the number of people tested, procedures for selecting test subjects, demographic characteristics of the test subjects, and procedures used to assess reliability and validity.

Are there any published validity/reliability studies for this instrument?

Some validation studies are published in scholarly journals. If the validation study of the survey instrument was published, please provide a standard citation including the title of the article, name of the journal, date of publication, volume and issue numbers, and page numbers.

Item 6

You are required to submit the data and documentation, such as codebooks and variable dictionaries. Please provide file names and format and size information as well as a description of the organization of the data. For example, indicate how the data records are laid out. The most usual layout is to store all of the information from a single individual on a single data record. In a few cases, the record layout may be different; for example, each record containing only some of the information about an individual.

Prevention Attachment B:

Substitution Appeal Form

State/Territory/tribe:

Date substitution application submitted:

Date denial received:

Date appeal submitted:

1. Contact information

Name of the applicant (first and last name):

 Mr.  Ms.  Dr.  Other _____________________

Organization:

Department:

Mailing address:

E-mail address:

Telephone: Fax:

2. Measure(s) being appealed

National Outcome Measure(s) (NOM) being appealed:

Summarize SAMHSA’s reason(s) for the denial of the substitution:

3. Rationale for the appeal

State the rationale for appealing SAMHSA’s decision:

4. Attach a copy of the original substitution application.

5. Additional data or analysis to support the appeal.

Describe any additional data or analysis that supports the appeal:

Prevention Attachment C:

Approved Substitute Data Submission Form

Create a separate form for each data source.

Grantee and Contact Information

State/Territory/tribe:

Name of contact person (first and last name):

 Mr.  Ms.  Dr.  Other _____________________

Organization:

Department:

Mailing address:

E-mail address:

Telephone: Fax:

Date

Enter the date when the Application Form To Substitute Data was submitted:

If final approval was obtained after an appeal process, enter the date when the appeal was filed:

Enter the date when approval to submit alternative data was obtained:

Measure(s)

Enter the NOMs measure(s) for which State-generated data are being substituted:

Prevention Attachment D:

2005 Block Grant Subrecipient Cost Band Worksheet

Subrecipient Name:

Date Form Completed:

Name of Contact Person:

Phone: E-mail Address:

Table 1: 2005 Subrecipient Program Detail

1	2	3	4	5
Program Name	Number of Participants4	Block Grant Dollars Expended on this Program	Average Cost per Client (Col 4/Col 3)	Average Per Client Cost Falls Within 2005 Cost Bands (Yes=1 No=0)
Universal Direct Programs				Universal Direct: $58.01–$693.98
1.
2.
3.
4.
Universal Indirect Programs				Universal Indirect $1.05–$82.26
1.
2.
3.
4.
Selective Programs				Selective $151.88–$6,409.29
1.
2.
3.
4.
Indicated Programs				Indicated $510.47–$4,888.44
1.
2.
3.
4.

Table 2: Subrecipient Cost Band Summary

	1	2
Program Type	Number of Programs	Number of Programs Falling Within Cost Bands
Universal Direct
Universal Indirect
Selective
Indicated
Total

Table 1: Progam Detail

1	2	3	4	5	6
Program Name	Number of Participants	Number of Program Hours Received	Total Cost of the Program	Average Cost Per Participant (Col 4/Col 2)	Average Cost Per Participant Falls Within 2005 Cost Bands (Yes=1 No=0)
Universal Direct Programs					Universal Direct: $58.01–$693.98
1.
2.
3.
4.
Universal Indirect Programs					Universal Indirect $1.05–$82.26
1.
2.
3.
4.
Selective Programs					Selective $151.88–$6,409.29
1.
2.
3.
4.
Indicated Programs					Indicated $510.47–$4,888.44
1.
2.
3.
4.

Table 2: Subrecipient Cost Band Summary

	1	2
Program Type	Number of Programs	Number of Programs Falling Within Cost Bands
Universal Direct
Universal Indirect
Selective
Indicated
Total

2005 Block Grant Subrecipient Cost Band Worksheet

for the Center for Substance Abuse Prevention (CSAP)

Substance Abuse Prevention Programs

Guidelines for Use

The 2005 Block Grant Subrecipient Cost Band Worksheet is designed to record the number of program participants, the amount of Block Grant dollars expended for each program, the average cost per program client, and the number of programs whose average client costs fall within the 2005 cost bands. These data will allow CSAP to meet its Performance Assessment Rating Tool (PART) and National Outcome Measures (NOMs) reporting requirements. In addition, this documentation of costs for prevention services is intended to benefit the grantees.

Subrecipient Information

Grant Information. At the top of the page, enter the name of the subrecipient, the contact information for the person completing this form, and the date on which the form was completed.

Table 1: Subrecipient Program Detail

Column 1: Program Name. In column 1, list the names of all programs that were funded in whole or in part with Block Grant funds during Federal fiscal year (FY) 2005. Add additional rows if necessary.

A program is defined as an activity, a strategy, or an approach intended to prevent an outcome or to alter the course of an existing condition. In substance abuse prevention, interventions may be used to prevent or lower the rate of substance use or substance abuse-related risk factors.

Separate table sections are provided for programs that are defined as Universal Direct, Universal Indirect, Selective, and indicated. Universal indirect services are defined as services that support prevention activities, such as population-based activities, and the provision of information and technical assistance. Universal direct, selective, and indicated services are defined as prevention program interventions that directly serve participants.

Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

Universal Direct. Interventions directly serve participants who have not been identified on the basis of individual risk.

Universal Indirect. Interventions support population-based activities and the provision of information and technical assistance.

Selective. Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

Indicated. Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

(Adapted from The Institute of Medicine Model of Prevention.)

Column 2: Number of Participants. In this column, specify the number of participants who took part in the preventive program during FY 2005. If this intervention was delivered to multiple groups, combine all groups and report the total. If it is an indirect program, use the estimated number of people reached during the reporting year.

Column 3: Block Grant Dollars Expended on This Program. In this column, report the total Block Grant dollars expended on the program during the reporting year. This should include all costs associated with the program, such as staff training, staff time, and materials, during the year.

Column 4: Average Cost per Client. Report the average cost per client. Calculate the average cost by dividing the Block Grant dollars expended on each program (column 3) by the number of clients served (column 2).

Column 5: Average per Client Cost Falls Within Cost Bands. Compare the average cost per client (column 4) with the 2005 cost bands for each program type. If the average cost per client falls within the specified interval, record a “1” in column 5. If the average cost is either higher or lower than the cost band interval, enter a zero in column 5.

3. Table 2: Subrecipient Cost Band Summary

Table 2 summarizes information recorded in Table 1.

Column 1: Number of Programs. In column 1, enter the total number of programs on which you reported in Table 1, by program types (Universal Direct, Universal Indirect, Selective, and Indicated). Total the number of programs in the last row.

Column 2: Number of Programs Falling Within Cost Bands. For each program type, enter the total number of programs that fell within the cost bands for that program type (i.e., programs that were coded “1” in Table 1, column 5).

Instructions for Completing the 2005 Block Grant Subrecipient Cost Band Worksheet

The 2005 Block Grant Subrecipient Cost Band Worksheet is an optional tool that States may use for their providers to record the number of program participants, the number of hours received, the cost of each program, the average cost per program participant, and the number of programs whose average participant costs fall within the 2005 cost bands. Data should be based on total cost of program not only the funding from CSAP. States may use an alternative approach to obtain data used to report the aggregate cost band data in Form P15 of the SAPT Block Grant Application. These worksheets are not required as part of that submission.

1. Subrecipient Information

Grant Information. At the top of the page, enter the name of the subrecipient, the contact information for the person completing this form, and the date on which the form was completed.

2. Table 1: Program Detail

Column 1: Program Name. In column 1, list the names of all programs that were funded in whole or in part with Block Grant funds during Federal fiscal year (FY) 2005. Add additional rows if necessary.

A program is defined as an activity, a strategy, or an approach intended to prevent an outcome or to alter the course of an existing condition. In substance abuse prevention, interventions may be used to prevent or lower the rate of substance use or substance abuse-related risk factors.

Separate table sections are provided for programs that are defined as Universal Direct, Universal Indirect, Selective, and indicated. Universal indirect services are defined as services that support prevention activities, such as population-based activities, and the provision of information and technical assistance. Universal direct, selective, and indicated services are defined as prevention program interventions that directly serve participants.

• Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Universal Indirect. Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Selective. Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated. Activities targeted to individuals identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

Column 2: Number of Participants. In this column, specify the number of participants who took part in the preventive program during FY 2005. If this intervention was delivered to multiple groups, combine all groups and report the total. If it is an indirect program, use the estimated number of people reached during the reporting year.

Column 3: Number of Program Hours Received. In this column, report the number of hours that program participants received over the course of the program.

Column 4: Total Cost of This Program. In this column, report the total of all costs expended on the program during the reporting year. This should include all costs associated with the program, such as staff training, staff time, and materials, during the year.

Column 5: Average Cost Per Participant. Report the average cost per participant. Calculate the average cost by dividing the Block Grant dollars expended on each program (column 4) by the number of participant s served (column 2).

Column 6: Average Cost Per Participant Falls Within Cost Bands. Compare the average cost per participant (column 5) with the 2005 cost bands for each program type. If the average cost per participant falls within the specified interval, record a “1” in column 5. If the average cost is either higher or lower than the cost band interval, enter a zero in column 5.

3. Table 2: Subrecipient Cost Band Summary

Table 2 summarizes information recorded in Table 1.

Column 1: Number of Programs. In column 1, enter the total number of programs on which you reported in Table 1, by program types (Universal Direct, Universal Indirect, Selective, and Indicated). Total the number of programs in the last row.

Column 2: Number of Programs Falling Within Cost Bands. For each program type, enter the total number of programs that fell within the cost bands for that program type (i.e., programs that were coded “1” in Table 1, column 5).

6/20/2007 5:03:39 PM

LIST OF FORMS

1 Face Page

2 Table of Contents

3 Funding Agreements/Certifications (PHS 5161)

4 Substance Abuse State Agency Spending Report

6 Substance Abuse Entity Inventory

6aA Prevention Strategy Report

7aA Treatment Utilization Matrix

7bB Number of Persons Served for Alcohol and Other Drug Use in
State-Funded Services By Age, Sex, Race/Ethnicity (Unduplicated Count)

8 Treatment Needs Assessment Summary Matrix

9 Treatment Needs by Age, Sex, and Race/Ethnicity

11 Intended Use Plan

12 Treatment Capacity Matrix

T1 Employment Status

T2 Living Status

T3 Criminal Justice Involvement

T4 Alcohol Use

T5 Other Drug Use

T6 Social Support of Recovery

T7 Retention

P1 NOMs Domain: Reduced Morbidity—Measure: 30-Day Use

P2 NOMs Domain: Reduced Morbidity—Measure: Perception of Risk/Harm of Use

P3 NOMs Domain: Reduced Morbidity—Measure: Age of First Use

P4 NOMs Domain: Reduced Morbidity—Measure: Perception of
Disapproval/Attitudes

P5 NOMs Domain: Employment/Education—Measure: Perception of Workplace
Policy

P6 NOMs Domain: Employment/Education—Measure: ATOD-Related Suspensions
and Expulsions

P7 NOMs Domain: Employment/Education—Measure: Average Daily School
Attendance Rate

P8 NOMs Domain: Crime and Criminal Justice—Measure: Alcohol-Related Traffic
Fatalities

P9 NOMs Domain: Crime and Criminal Justice—Measure: Alcohol- and Drug-
Related Arrests

P10 NOMs Domain: Social Connectedness—Measure: Family Communications
Around Drug and Alcohol Use

P11 NOMs Domain: Retention—Measure: Youth Seeing, Reading, Watching, or
Listening to a Prevention Message

P12a and P12b Number of Persons Served by Age, Race, and Ethnicity—NOMs
Domain: Access/Capacity—Measure: Persons Served by Age,
Race, and Ethnicity

P13 Number of Persons Served by Type of Intervention—NOMs Domain:
Access/Capacity—Measure: Persons Served by Type of Intervention

P14 Evidence-Based Programs and Strategies by Type of Intervention—NOMs
Domain: Retention—NOMs Domain: Use of Evidence-Based Programs—
Measure: Evidence-Based Programs and Strategies

P15 Services Provided Within Cost Bands—NOMs Domain: Cost Effectiveness—
Measure: Services Provided Within Cost BandsP1 Number of Persons Served

P2 Number of Evidenced-Based Programs, Practices, and Policies

P3 Perception of Risk/Harm of and Unfavorable Attitudes Toward
Substance Use by Those Under Age 21

P4 Use of Substances During the Past 30 Days

APPENDIX A

STATE PROJECT OFFICERS’ DIRECTORY FOR

CENTER FOR SUBSTANCE ABUSE TREATMENT

CENTER FOR SUBSTANCE ABUSE PREVENTION

As of June 6, 2007

(The electronic block grant application system (BGAS) will contain up-to-date

information on each State’s respective State Project Officers)

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Division of State and Community Assistance Performance Partnership Grant Branch Telephone: (240) 276-2890 Substance Abuse Prevention and Treatment Block Grant Program State Project Officer Directory
State	Project Officers	Telephone	Facsimile	E-Mail
Alabama	Juli Harkins	(240) 276-2967	(240) 276-2900	[email protected]
Alaska	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	[email protected]
Arizona	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Arkansas	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
California	Greg Grass	(240) 276-2919	(240) 276-2900	[email protected]
Colorado	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Connecticut	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
Delaware	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
District of Columbia	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
Florida	Juli Harkins	(240) 276-2967	(240) 276-2900	[email protected]
Georgia	Brandon Johnson	(240) 276-2889	(240) 276-2900	[email protected]
Hawaii	Greg Grass	(240) 276-2919	(240) 276-2900	[email protected]
Idaho	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	[email protected]
Illinois	Lisa Creatura	(240) 276-2821	(240) 276-2900	[email protected]
Indiana	Lisa Creatura	(240) 276-2821	(240) 276-2900	[email protected]
Iowa	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	[email protected]
Kansas	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Kentucky	Juli Harkins	(240) 276-2967	(240) 276-2900	[email protected]
Louisiana	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Maine	Ann Mahony	(240)-276-2969	(240) 276-2900	[email protected]
Maryland	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
Massachusetts	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
Michigan	Lisa Creatura	(240) 276-2821	(240) 276-2900	[email protected]
Minnesota	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	[email protected]
Red Lake Band of the Chippewa (MN)	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	[email protected]
Mississippi	Juli Harkins	(240) 276-2967	(240) 276-2900	[email protected]
Missouri	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Montana	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	[email protected]
Nebraska	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Nevada	Greg Grass	(240) 276-2919	(240) 276-2900	[email protected]
New Hampshire	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
New Jersey	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
New Mexico	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
New York	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
North Carolina	Brandon Johnson	(240) 276-2889	(240) 276-2900	[email protected]
North Dakota	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	[email protected]
Ohio	Lisa Creatura	(240) 276-2821	(240) 276-2900	[email protected]
Oklahoma	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Oregon	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	[email protected]
Pennsylvania	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
Rhode Island	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
South Carolina	Brandon Johnson	(240) 276-2889	(240) 276-2900	[email protected]
South Dakota	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	[email protected]
Tennessee	Juli Harkins	(240) 276-2967	(240) 276-2900	[email protected]
Texas	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Utah	Greg Grass	(240) 276-2919	(240) 276-2900	[email protected]
Vermont	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
Virginia	Brandon Johnson	(240) 276-2889	(240) 276-2900	[email protected]
Washington	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	[email protected]
West Virginia	Juli Harkins	(240) 276-2967	(240) 276-2900	[email protected]
Wisconsin	Lisa Creatura	(240) 276-2821	(240) 276-2900	[email protected]
Wyoming	Greg Grass	(240) 276-2919	(240) 276-2900	[email protected]
American Samoa	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Commonwealth of the Northern Mariana Islands	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Guam	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Marshall Islands	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Micronesia	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Palau	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Puerto Rico	Brandon Johnson	(240) 276-2889	(240) 276-2900	[email protected]
U.S. Virgin Islands	Brandon Johnson	(240) 276-2889	(240) 276-2900	[email protected]

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention Division of State Programsand Community Assistance Telephone: (240) 276-2570 Substance Abuse Prevention and Treatment Block Grant Program State Project Officer Directory
State	Project Officers	Telephone	Facsimile	E-Mail
Alabama	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Alaska	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Arizona	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Arkansas	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
California	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
Colorado	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Connecticut	Andrea Harris	(240) 276-2441	(240) 276-2580	[email protected]
Delaware	Flo Dwek	(240) 276-2574	(240) 276-2580	[email protected]
District of Columbia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Florida	Bettina Scott	(240) 276-2493	(240) 276-2580	[email protected]
Georgia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Hawaii	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Idaho	Debbie Castell, Interim	(240) 276-2496	(240) 276-2580	[email protected]
Illinois	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Indiana	Bettina Scott	(240) 276-2493	(240) 276-2580	[email protected]
Iowa	Tonia Gray	(240) 276-2492	(240) 276-2580	[email protected]
Kansas	Debbie Castell, Interim	(240) 276-2496	(240) 276-2580	[email protected]
Kentucky	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
Louisiana	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Maine	Flo Dwek	(240) 276-2574	(240) 276-2580	[email protected]
Maryland	Flo Dwek	(240) 276-2574	(240) 276-2580	[email protected]
Massachusetts	Flo Dwek	(240) 276-2574	(240) 276-2580	[email protected]
Michigan	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Minnesota	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Red Lake Band of the Chippewa (MN)	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Mississippi	Bettina Scott	(240) 276-2493	(240) 276-2580	[email protected]
Missouri	Debbie Castell, Interim	(240) 276-2496	(240) 276-2580	[email protected]
Montana	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Nebraska	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Nevada	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
New Hampshire	Andrea Harris	(240) 276-2441	(240) 276-2580	[email protected]
New Jersey	Andrea Harris	(240) 276-2441	(240) 276-2580	[email protected]
New Mexico	Debbie Castell, Interim	(240) 276-2496	(240) 276-2580	[email protected]
New York	Andrea Harris	(240) 276-2441	(240) 276-2580	[email protected]
North Carolina	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
North Dakota	Tonia Gray	(240) 276-2492	(240) 276-2580	[email protected]
Ohio	Tonia Gray	(240) 276-2492	(240) 276-2580	[email protected]
Oklahoma	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Oregon	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
Pennsylvania	Flo Dwek	(240) 276-2574	(240) 276-2580	[email protected]
Rhode Island	Dan Fletcher	(240) 276-2578	(240) 276-2580	[email protected]
South Carolina	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
South Dakota	Tonia Gray	(240) 276-2492	(240) 276-2580	[email protected]
Tennessee	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
Texas	Debbie Castell, Interim	(240) 276-2496	(240) 276-2580	[email protected]
Utah	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Vermont	Andrea Harris	(240) 276-2441	(240) 276-2580	[email protected]
Virginia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Washington	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
West Virginia	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Wisconsin	Tonia Gray	(240) 276-2492	(240) 276-2580	[email protected]
Wyoming	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
American Samoa	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Guam	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Mariana Islands	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Marshall Islands	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Micronesia	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Palau	Allen Ward	(240) 276-2444	(240) 276-2580	[email protected]
Puerto Rico	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
U.S. Virgin Islands	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]

Appendix B

FY 2008 Allocation Table for SAPT Block Grant

and

List of “Designated States”

Designated States1 for FY 2008 SAPT Block Grant Uniform Application
State2	Rate3	FY 2008 SAPTBG4	FY 1991 ADMSBG5	% Change1991-2008	HIV Set-Aside
Alabama	11.4	$23,762,336	$12,409,695	91%	$1,188,117
Alaska	8.4	$4,628,992	$2,449,664	89%
Arizona	10.8	$31,531,750	$13,840,593	128%	$1,576,588
Arkansas	6.7	$13,286,191	$4,807,518	176%
California	11.3	$249,872,806	$130,425,411	92%	$12,493,640
Colorado	7.3	$23,731,085	$13,956,718	70%
Connecticut	19.0	$16,747,115	$13,882,960	21%	$837,356
Delaware	20.9	$6,590,346	$3,148,031	109%	$329,518
District of Columbia	128.4	$6,590,346	$4,790,552	38%	$329,518
Florida	27.9	$94,317,359	$47,792,540	97%	$4,715,868
Georgia	25.7	$50,338,292	$17,701,223	184%	$2,516,915
Hawaii	8.5	$7,144,836	$4,590,998	56%
Idaho	1.7	$6,882,075	$2,173,396	217%
Illinois	15.1	$69,617,036	$48,009,708	45%	$3,480,852
Indiana	6.5	$33,185,767	$14,663,226	126%
Iowa	3.2	$13,474,900	$8,582,512	57%
Kansas	3.9	$12,246,431	$5,948,610	106%
Kentucky	6.2	$20,589,104	$11,290,513	82%
Louisiana	21.2	$25,755,724	$17,671,416	46%	$1,287,786
Maine	1.6	$6,590,346	$2,860,348	130%
Maryland	28.5	$31,862,443	$22,705,061	40%	$1,593,122
Designated States1 for FY 2008 SAPT Block Grant Uniform Application
Massachusetts	10.8	$33,905,634	$26,059,220	30%	$1,695,282
Michigan	8.1	$57,686,286	$40,890,802	41%
Minnesota	4.4	$21,612,573	$14,843,236	46%
Red Lake-Chippewa (MN)		$532,670	$390,000	37%
Mississippi	13.2	$14,205,812	$4,749,463	199%	$710,291
Missouri	6.7	$26,062,300	$16,984,801	53%
Montana	2.1	$6,590,346	$1,940,827	240%
Nebraska	3.0	$7,863,913	$4,662,147	69%
Nevada	12.3	$12,863,681	$4,317,190	198%	$643,184
New Hampshire	2.6	$6,590,346	$1,980,819	233%
New Jersey	14.7	$46,768,908	$35,398,346	32%	$2,338,445
New Mexico	7.1	$8,682,872	$4,209,623	106%
New York	32.7	$115,088,891	$93,451,518	23%	$5,754,444
North Carolina	10.9	$38,478,293	$16,092,236	139%	$1,923,915
North Dakota	1.6	$5,135,570	$1,708,762	201%
Ohio	6.8	$66,416,367	$38,367,574	73%
Oklahoma	7.9	$17,649,089	$8,250,691	114%
Oregon	6.0	$16,214,407	$10,323,828	57%
Pennsylvania	12.1	$58,870,653	$46,860,078	26%	$2,943,533
Rhode Island	8.3	$6,590,346	$4,952,253	33%
South Carolina	15.7	$20,499,314	$9,718,124	111%	$1,024,966
South Dakota	2.4	$4,748,970	$1,893,408	151%
Tennessee	14.1	$29,639,062	$14,221,946	108%	$1,481,953
Texas	13.6	$135,487,606	$62,406,552	117%	$6,774,380
Designated States1 for FY 2008 SAPT Block Grant Uniform Application
Utah	2.6	$17,071,988	$7,325,996	133%
Vermont	1.0	$5,077,658	$1,907,282	166%
Virginia	8.5	$42,930,418	$21,505,683	100%
Washington	7.7	$34,849,724	$17,928,552	94%
West Virginia	4.1	$8,678,416	$3,501,025	151%
Wisconsin	2.2	$25,674,056	$18,849,237	36%
Wyoming	1.2	$3,299,412	$972,873	239%
Subtotal, States		$1,644,510,861	$940,364,785		$55,639,673
American Samoa		$327,906
Guam		$886,028
Republic of the Marshall Islands		$290,983
Federated States of Micronesia		$612,461
Commonwealth of the Northern Mariana Islands		$396,187
Republic of Palau		$109,485
Puerto Rico	26.4	$21,798,621	$12,608,307	73%	$1,089,931
Virgin Islands, U.S.	15.6	$621,642	$520,633	19%	$31,082
Subtotal, Territories		$25,043,313	$13,128,940		$1,121,013
SAMHSA Set-Aside		$87,871,272
Total, SAPTBG		$1,757,425,446	$953,493,725		$56,760,686

1. The term “designated State” means any State whose rate of cases of acquired immune deficiency syndrome (AIDS) is 10 or more such cases per 100,000 individuals (as indicated by the number of such cases reported to and confirmed by the Centers for Disease Control and Prevention (CDC) for the most recent calendar year for which the data are available (See 45 CFR 96.128(b).

2. Total of 24 “designated States” (including District of Columbia, Puerto Rico, and the Virgin Islands).

3. The most recent data published prior to October 1, 2007 by the CDC is Table 14, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through 2005-United States, HIV/AIDS Surveillance Report 2005 Vol. 17, U.S. Department of Health and Human sServices, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS, Prevention, Surveillance, and Epidemiology. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 or 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/table14.htm

4. Source: FY 2008 Justification of Estimates for Appropriations Committees

5. FY 1991 is the base year to determine amount of set-aside (Source: Section 1924 (b)(4) of the Public Health Service Act).

APPENDIX A

STATE PROJECT OFFICERS’ DIRECTORY FOR

CENTER FOR SUBSTANCE ABUSE TREATMENT

CENTER FOR SUBSTANCE ABUSE PREVENTION

As of May 1, 2006

(The electronic block grant application system (BGAS) will contain up-to-date

information on each State’s respective State Project Officers)

LIST OF DESIGNATED HIV STATES

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Division of State and Community Assistance Performance Partnership Grant Branch Telephone: (240) 276-2890 Substance Abuse Prevention and Treatment Block Grant Program State Project Officer Directory
State	Project Officers	Telephone	Facsimile	E-Mail
Alabama	Ruby Neville, Interim	(240) 276-2902	(240) 276-2900	[email protected]
Alaska	Sherrye Fowler, Interim	(240) 276-2906	(240) 276-2900	[email protected]
Arizona	Rick Dulin	(240) 276-2894	(240) 276-2900	[email protected]
Arkansas	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
California	Rick Dulin	(240) 276-2894	(240) 276-2900	[email protected]
Colorado	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Connecticut	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
Delaware	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
District of Columbia	Veronica Munson, Interim	(240) 276-2901	(240) 276-2900	[email protected]
Florida	Ruby Neville, Interim	(240) 276-2902	(240) 276-2900	[email protected]
Georgia	Ruby Neville	(240) 276-2902	(240) 276-2900	[email protected]
Hawaii	Rick Dulin	(240) 276-2894	(240) 276-2900	[email protected]
Idaho	Sherrye Fowler, Interim	(240) 276-2906	(240) 276-2900	[email protected]
Illinois	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Indiana	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Iowa	Michael Yesenko	(240) 276-2915	(240) 276-2900	[email protected]
Kansas	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Kentucky	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Louisiana	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Maine	Ann Mahony	(240)-276-2969	(240) 276-2900	[email protected]
Maryland	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
Massachusetts	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
Michigan	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Minnesota	Michael Yesenko	(240) 276-2915	(240) 276-2900	[email protected]
Red Lake Band of the Chippewa (MN)	Michael Yesenko	(240) 276-2915	(240) 276-2900	[email protected]
Mississippi	Veronica Munson, Interim	(240) 276-2901	(240) 276-2900	[email protected]
Missouri	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Montana	Sherrye Fowler, Interim	(240) 276-2906	(240) 276-2900	[email protected]
Nebraska	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Nevada	Rick Dulin	(240) 276-2894	(240) 276-2900	[email protected]
New Hampshire	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
New Jersey	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
New Mexico	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
New York	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
North Carolina	Ruby Neville	(240) 276-2902	(240) 276-2900	[email protected]
North Dakota	Michael Yesenko	(240) 276-2915	(240) 276-2900	[email protected]
Ohio	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Oklahoma	Carol Coley	(240) 276-2892	(240) 276-2900	[email protected]
Oregon	Sherrye Fowler, Interim	(240) 276-2906	(240) 276-2900	[email protected]
Pennsylvania	Veronica Munson	(240) 276-2901	(240) 276-2900	[email protected]
Rhode Island	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
South Carolina	Ruby Neville	(240) 276-2902	(240) 276-2900	[email protected]
South Dakota	Michael Yesenko	(240) 276-2915	(240) 276-2900	[email protected]
Tennessee	Carol Coley, Interim	(240) 276-2892	(240) 276-2900	[email protected]
Texas	Melissa Rael	(240) 276-2903	(240) 276-2900	[email protected]
Utah	Rick Dulin	(240) 276-2894	(240) 276-2900	[email protected]
Vermont	Ann Mahony	(240) 276-2969	(240) 276-2900	[email protected]
Virginia	Ruby Neville	(240) 276-2902	(240) 276-2900	[email protected]
Washington	Sherrye Fowler, Interim	(240) 276-2906	(240) 276-2900	[email protected]
West Virginia	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Wisconsin	Terrence Schomburg, Interim	(240) 276-2907	(240) 276-2900	[email protected]
Wyoming	Rick Dulin	(240) 276-2894	(240) 276-2900	[email protected]
American Samoa	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Commonwealth of the Northern Mariana Islands	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Guam	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Marshall Islands	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Micronesia	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Palau	Steven Shapiro	(240) 276-2908	(240) 276-2900	[email protected]
Puerto Rico	Ruby Neville	(240) 276-2902	(240) 276-2900	[email protected]
U.S. Virgin Islands	Ruby Neville	(240) 276-2902	(240) 276-2900	[email protected]

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention Division of State and Community Assistance Telephone: (240) 276-2570 Substance Abuse Prevention and Treatment Block Grant Program State Project Officer Directory
State	Project Officers	Telephone	Facsimile	E-Mail
Alabama	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Alaska	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Arizona	Allen Ward	(240) 276-2444	(240) 276-2430	[email protected]
Arkansas	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
California	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
Colorado	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Connecticut	Grant Hills	(240) 276-2562	(240) 276-2580	[email protected]
Delaware	Grant Hills	(240) 276-2562	(240) 276-2580	[email protected]
District of Columbia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Florida	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Georgia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Hawaii	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Idaho	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Illinois	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Indiana	Tom Deloe	(240) 276-2404	(240) 276-2410	[email protected]
Iowa	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Kansas	Susan Marsiglia	(240) 276-2568	(240) 276-2580	[email protected]
Kentucky	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
Louisiana	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Maine	Dan Fletcher	(240) 276-2578	(240) 276-2580	[email protected]
Maryland	Dan Fletcher	(240) 276-2578	(240) 276-2580	[email protected]
Massachusetts	Dan Fletcher	(240) 276-2578	(240) 276-2580	[email protected]
Michigan	Mickey Smith	(240) 276-2406	(240) 276-2580	[email protected]
Minnesota	Tom Deloe	(240) 276-2404	(240) 276-2410	[email protected]
Red Lake Band of the Chippewa (MN)	Kelly Cosby	(240) 276-2478	(240) 276-2410	[email protected]
Mississippi	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
Missouri	Susan Marsiglia	(240) 276-2568	(240) 276-2580	[email protected]
Montana	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
Nebraska	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Nevada	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
New Hampshire	Grant Hills	(240) 276-2562	(240) 276-2580	[email protected]
New Jersey	Grant Hills	(240) 276-2562	(240) 276-2580	[email protected]
New Mexico	Susan Marsiglia	(240) 276-2568	(240) 276-2580	[email protected]
New York	Grant Hills	(240) 276-2562	(240) 276-2580	[email protected]
North Carolina	Donna Simms- d’Almeida	(240) 276-2586	(240) 276-2580	[email protected]
North Dakota	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Ohio	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Oklahoma	Jon Dunbar	(240) 276-2573	(240) 276-2580	[email protected]
Oregon	Ivette Ruiz	(240) 276-1511	(240) 276-2430	[email protected]
Pennsylvania	Dan Fletcher	(240) 276-2578	(240) 276-2580	[email protected]
Rhode Island	Dan Fletcher	(240) 276-2578	(240) 276-2580	[email protected]
South Carolina	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
South Dakota	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Tennessee	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
Texas	Susan Marsiglia	(240) 276-2568	(240) 276-2580	[email protected]
Utah	Debbie Castell	(240) 276-2496	(240) 276-2580	[email protected]
Vermont	Grant Hills	(240) 276-2562	(240) 276-2580	[email protected]
Virginia	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
Washington	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
West Virginia	Karen Salem	(240) 276-2575	(240) 276-2580	[email protected]
Wisconsin	Tom Deloe	(240) 276-2404	(240) 276-2410	[email protected]
Wyoming	Mary Joyce Pruden	(240) 276-2582	(240) 276-2580	[email protected]
American Samoa	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Guam	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Mariana Islands	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Marshall Islands	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Micronesia	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Palau	Alejandro Arias	(240) 276-2569	(240) 276-2580	[email protected]
Puerto Rico	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]
U.S. Virgin Islands	Clarese Holden	(240) 276-2579	(240) 276-2580	[email protected]

HIV DESIGNATED STATES

FOR FY 20087

Designated States1 for FY 2007 SAPT Block Grant Uniform Application
State2	Rate3	FY 2007 SAPTBG4	FY 1991 ADMSBG5	% Change1991-2007	HIV Set-Aside
Alabama	10.3	$23,778,096	$12,409,695	92%	$1,188,903
Alaska	8.4	$4,632,062	$2,449,664
Arizona	9.8	$31,552,663	$13,840,593	128%
Arkansas	6.7	$13,295,003	$4,807,518
California	13.0	$250,038,523	$130,425,411	92%	$12,501,926
Colorado	7.3	$23,746,823	$13,956,718
Connecticut	18.4	$16,758,222	$13,882,960	21%	$837,911
Delaware	18.9	$6,594,717	$3,148,031	109%	$329,736
District of Columbia	179.2	$6,594,717	$4,790,552	38%	$329,736
Florida	33.5	$94,379,912	$47,792,540	97%	$4,718,996
Georgia	18.6	$50,371,677	$17,701,223	185%	$2,518,584
Hawaii	10.8	$7,149,575	$4,590,998	56%	$357,479
Idaho	1.6	$6,886,639	$2,173,396	217%
Illinois	13.2	$69,663,207	$48,009,708	45%	$3,483,160
Indiana	6.3	$33,207,776	$14,663,226	126%
Iowa	2.2	$13,483,837	$8,582,512	57%
Kansas	4.2	$12,254,553	$5,948,610	106%
Kentucky	6.1	$20,602,759	$11,290,513	82%
Louisiana	22.4	$25,772,805	$17,671,416	46%	$1,288,640
Maine	4.6	$6,594,717	$2,860,348	131%
Maryland	26.1	$31,883,575	$22,705,061	40%	$1,594,179
Massachusetts	8.8	$33,928,121	$26,059,220	30%
Michigan	6.5	$57,724,545	$40,890,802	41%
Minnesota	4.3	$21,626,907	$14,843,236	46%
Red Lake-Chippewa (MN)		$523,023	$390,000	34%
Mississippi	16.5	$14,215,234	$4,749,463	199%	$710,762
Missouri	6.8	$26,079,585	$16,984,801	54%
Montana	0.8	$6,594,717	$1,940,827	240%
Nebraska	3.9	$7,869,129	$4,662,147	69%
Nevada	13.1	$12,872,212	$4,317,190	198%	$643,611
New Hampshire	3.2	$6,594,717	$1,980,819	233%
New Jersey	21.2	$46,799,926	$35,398,346	32%	$2,339,996
New Mexico	9.6	$8,688,631	$4,209,623	106%
New York	39.7	$115,165,220	$93,451,518	23%	$5,758,261
North Carolina	13.3	$38,503,813	$16,092,236	139%	$1,925,191
North Dakota	2.7	$5,138,976	$1,708,762	201%
Ohio	5.8	$66,460,416	$38,367,574	73%
Oklahoma	5.5	$17,660,794	$8,250,691	114%
Oregon	7.8	$16,225,161	$10,323,828	57%
Pennsylvania	13.1	$58,909,697	$46,860,078	26%	$2,945,485
Rhode Island	12.2	$6,594,717	$4,952,253	33%	$329,736
South Carolina	18.1	$20,512,909	$9,718,124	111%	$1,025,645
South Dakota	1.6	$4,752,119	$1,893,408	151%
Tennessee	13.1	$29,658,719	$14,221,946	109%	$1,482,936
Texas	14.7	$135,577,464	$62,406,552	117%	$6,778,873
Utah	3.3	$17,083,310	$7,325,996	133%
Vermont	2.7	$5,081,025	$1,907,282	166%
Virginia	10.7	$42,958,890	$21,505,683	100%	$2,147,944
Washington	7.2	$34,872,837	$17,928,552	95%
West Virginia	5.1	$8,684,172	$3,501,025	148%
Wisconsin	3.2	$25,691,084	$18,849,237	36%
Wyoming	3.6	$3,301,600	$972,873	239%
Subtotal, States		$1,645,601,528			$55,237,609
American Samoa		$328,123
Guam		$886,616
Marshall Islands		$291,176
Federated States of Micronesia		$612,868
Commonwealth of the Northern Mariana Islands		$396,450
Palau		$109,558
Puerto Rico	23.4	$21,813,077	$12,608,307	73%	$1,090,654
Virgin Islands, U.S.	18.4	$622,054	$520,633	19%	$31,103
Subtotal, Territories		$25,059,922			$1,121,757
SAMHSA Set-Aside		$87,929,550
Total, SAPTBG		$1,758,591,000			$56,359,366

The term “designated State” means any State whose rate of cases of acquired immune deficiency syndrome (AIDS) is 10 or more such cases per 100,000 individuals (as indicated by the number of such cases reported to and confirmed by the Centers for Disease Control and Prevention (CDC) for the most recent calendar year for which the data are available (See 45 CFR 96.128(b).

Total of 24 “designated States” (including District of Columbia, Puerto Rico, and the Virgin Islands).

The most recent data published prior to October 1, 2005 by the CDC is Table 14, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through 2004-United States, HIV/AIDS Surveillance Report 2004 Vol. 16, U.S. Department of Health and Human services, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS, Prevention, Surveillance, and Epidemiology. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 0r 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/table14.htm.

Source: FY 2007 Justification of Estimates for Appropriations Committees http://www.samhsa.gov/Budget/index.aspx.

FY 1991 is the base year to determine amount of set-aside (Source: Section 1924 (b)(4) of the Public Health Service Act).

2/5/2021 3:05:48 PM

1 ^?The term State is used to refer to all the States and territories eligible to receive Substance Abuse Prevention and Treatment Block Grant funds (See 42 U.S.C. 300x-6446 and 45 C.F.R. 96.121).

2 Table 2, AIDS cases and annual rates (per 100,000 population), by area and age group, reported through 2001 -United States, HIV/AIDS Surveillance Report, 2001 (Vol. 13, No. 2). Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (pages 1-44). Also available at “http://www.cdc.gov/hiv/stats/hasr1302/table2.htm The most recent data published prior to October 1, 2004 by the CDC is Table 14, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through 2002-United States, HIV/AIDS Surveillance Report 2004 Vol. 14, U.S. Department of Health and Human services, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS, Prevention, Surveillance, and Epidemiology. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 or 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2002report/table14.htm.”

3 Table 14, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through 2004—United States, HIV/AIDS Surveillance Report, 2004 (Vol. 16). Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (pages 1-46). Also available at “http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/table14.htm.”

The most recent data published prior to October 1, 2007 by the CDC is Table 14, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through 2005-United States, HIV/AIDS Surveillance Report 2005 Vol. 17, U.S. Department of Health and Human sServices, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS, Prevention, Surveillance, and Epidemiology. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 or 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/table14.htm

4¹ For indirect programs, enter the estimated number of people reached (e.g., by media campaign).

2

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