B1d SPFSIGIII_IV_V B1d SPFSIGIII_IV_VCLIPart 2

ATTACHMENT B1d: SPF SIG III, IV & V CLI Part 2

Form Approved

O MB No. XXXX-XXXX

Expiration Date XX/XX/XXXX

Strategic Prevention Framework
State Incentive Grant
(SPF SIG)

Cohort III, IV & V Cross-Site Evaluation
Community Level Instrument (CLI)
(Part II):
Prevention Intervention Strategies
May 2009

Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Prevention

Burden Statement: Public reporting burden of this collection of information is estimated to average 1 hour per response.  Send all comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 8-1099, Choke Cherry Road, Rockville, MD 20857.  An agency may not sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  The control number for this project is XXXXX.

Table of Contents

Prevention Strategy Form 1

Information and Directions 1

Prevention Strategy Information 5

Adaptations 8

Prevention Intervention Outcomes 10

Closing Question 11

Prevention Education Sub-Form 11

Alternative Drug-Free Activities Sub-Form 14

Problem Identification and Referral Sub-Form 18

Community-Based Processes Sub-Form 20

Environmental Strategies Sub-Form 23

Information Dissemination Sub-Form 25

Other Activities or Services Delivered to Individuals Sub-Form 27

Other Activities or Services Not Delivered to Individuals Sub-Form 30

Prevention Strategy Form

Information and Directions

The Community Level Instrument (CLI) is designed as a two-part survey. Part I collects data about the subrecipient community’s progress through the Strategic Prevention Framework State Incentive Grant (SPF SIG) Initiative. Part II collects information about the specific prevention strategies being implemented by the community. Data collected from the survey will be used to evaluate the effectiveness of the Strategic Prevention Framework.

Completion of this survey is a requirement of accepting funding from CSAP under the SPF-SIG grant initiative. However, respondents may choose not to answer a specific question and respondents may end the survey at any time. Respondents are required to complete Part II a minimum of twice per fiscal year, though optimally data will be updated monthly. To minimize respondent burden and decrease completion time this web-based survey allows information entered in previous reporting periods to be pre-filled where possible and skip patterns are used to automatically take you to the appropriate question based on your responses.

Each sub-recipient community will complete a separate Part II form for each prevention strategy implemented. For example, if the community is implementing both a participant-based education prevention strategy and an environmental prevention strategy, they will complete two Part II forms. Similarly, if the community is implementing two different participant-based education prevention strategies, they will also complete two separate Part II forms.

Each subrecipient community will be assigned a unique identification. This identification will be used to link together all the data collected from a community throughout the grant period without the need to identify the community by name. Each prevention strategy will also be assigned a unique identification number. This identification will be linked to participant level data in order to provide a more complete understanding of each type of strategy used within an intervention implemented by subrecipient communities. No individuals will be identified in the reporting of results.

Throughout this document, the term “you” refers to the subrecipient community that has received SPF SIG funding from the state/tribe/jurisdiction. This could be an organization, coalition, or other entity. If this is a community coalition, the Project Director for the SPF SIG subrecipient community project is required to complete the instrument, with input from other coalition members as needed.

You are strongly encouraged to obtain input from others involved with the SPF SIG funded project. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, such as the project coordinator, evaluator, intervention delivery staff, and others, as appropriate.

People you may want to include in responding to this form:

• Project Director

• Project Coordinator

• Intervention delivery staff

• Evaluator

• Coalition representative(s)

Make sure to read all of the directions and examples, which are provided in italics.

As you enter your data, you will be able to save your work and come back to it at another time. You may also write your responses to the open-ended questions requiring narrative information in advance using a word processor and copy and paste them into the web-based survey.

If you need assistance in using the web-based data entry system, contact the Help Desk by phone at 1-888-DITIC-4-U or by e-mail at [email protected].

There are several terms used throughout this instrument for which CSAP provides the definitions on the following pages. In addition, the link below provides access to SAMHSA’s prevention glossary.

https://preventionplatform.samhsa.gov/MacroHQ/Glossary2/dssglossary.cfm?sect_id=1&topic_id=99&CFID=2112072&CFTOKEN=48724502

Definition of Terms

• Capacity building refers to activities conducted to improve the ability of an organization or community to deliver substance abuse prevention services, such as improving organizational resources; improving awareness about substance abuse problems; building new relationships or strengthening existing relationships among coalitions, groups, and organizations involved in substance abuse prevention; and working to ensure prevention intervention activities and outcomes continue after funding ends.

• Community coalition is a union of people and organizations working for a common cause.

• Community needs and resources assessments examine needs external to the organization and include community readiness, rates of substance use, prevention resources (e.g., call centers and trained counselors), partnerships, community prevention experience, and other monetary and non-monetary resources.

• Community readiness is the community's level of awareness of, interest in, and ability and willingness to support substance abuse prevention initiatives. More broadly, connotes readiness for changes in community knowledge, attitudes, motives, policies, and actions.

• Consequences are defined as the social, economic and health problems associated with the use of alcohol and illicit drugs e.g., illnesses related to alcohol (cirrhosis, fetal effects), drug overdose deaths, crime, and car crashes or suicides related to alcohol or drugs.

• Consumption patterns are the way in which people drink, smoke and use drugs. Consumption includes overall consumption, acute or heavy consumption, consumption in risky situations (e.g., drinking and driving) and consumption by high-risk groups (e.g., youth, college students, and pregnant women).

• Cultural competence is the attainment of knowledge, skills, and attitudes to enable administrators and practitioners to provide for diverse populations. This includes an understanding of that group’s or members’ language, beliefs, norms, and values, as well as socioeconomic and political factors that may have a significant impact on their well-being, and incorporating those variables into programs.

• Environmental approaches are efforts to establish or change community standards, codes, and attitudes and thus influence incidence and prevalence of substance abuse. Approaches can center on legal and regulatory issues or can relate to service and action-oriented initiatives. Examples include TA to communities to maximize enforcement of laws governing availability and distribution of legal drugs, product pricing strategies, and modification of practices of advertising alcohol and tobacco.

• Evaluation plans are systematic blueprints detailing all the evaluation aspects of the project including the database structures to manage the project data.

• Intervening variables are factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of substance use and related risk behaviors and their subsequent consequences. These variables are the focus of prevention strategies, changes in which are then expected to affect consumption and consequences.

• Intervention-level evaluation activities are activities to measure the impact and assess the implementation of specific interventions or strategies within the overall set of selected interventions.

• Interventions are funded activities carried out under the auspices of the SPF SIG grant, and target a variety of subpopulations with the objective of improving substance use outcomes.

• Key stakeholders are all of the members of the community who have a vested interest (a stake) in the activities or outcomes of a substance abuse intervention.

• Logic models are graphic depictions of the components of a theory, program, initiative, or activity that shows the program's components and plausible linkages between the program components.

• Media literacy programs foster the ability to analyze and evaluate messages in the media (e.g., working with children to teach them to evaluate the images and messages in a beer ad).

• Organizational needs assessments examine an organization’s internal needs and include assessments of leadership, human resources, technical resources (e.g., telephones, computers, or appropriate software), infrastructure (e.g., facility, staff offices, conference rooms), funding sources, etc.

• Prevention system is the entire set of agencies, organizations, and persons that contribute to efforts to prevent substance abuse and related problems within the community.

• Primary grantee refers to the administrative entity of a jurisdiction (such as the state, tribe, or territory) receiving SPF SIG funds for delivery of substance abuse prevention programs.

• Social marketing uses the principles of commercial marketing to develop, implement, and evaluate programs designed to influence the behavior of a target audience. Rather than dictating the way that information is to be conveyed, social marketing involves listening to the needs and desires of the target audience and building the program from there.

• Strategic plans at a minimum will: specify the priorities that will be targeted; articulate a vision for activities to address needs; describe infrastructure needed to select and implement interventions; identify resources and training requirements; include plans for sustaining the infrastructure and services; and identify milestones and outcomes against which to gauge performance. Strategic plan development is Step 3 of the SPF.

• Sub-recipient communities are the entities (usually community based organizations, schools, or coalitions) that receive funds from the grantee to carry out SPF SIG activities or prevention interventions.

• Sustainability is the process through which a prevention system becomes a norm and is integrated into ongoing operations. Sustainability is vital to ensuring that prevention values and processes are firmly established, that partnerships are strengthened, and that financial and other resources are secured over the long term.

Prevention Strategy Information

Name of Prevention Intervention: ^{B, F (autofill from current CLI I)}

Name of Strategy ^{B, F (autofill from current CLI I)}

Unique Identifier: ^{B, F (autofill from Baseline)}

Strategy Type: ^{B, F (autofill from Baseline)}

1. What specific consumption patterns and/or consequences is the prevention intervention strategy intended to target? (Select all that apply) ^{B, F (autofill at F)}

• Underage use of alcohol

• Any use of alcohol

• Heavy use of alcohol

• Binge drinking

• Any use of tobacco under age 18

• Any use of tobacco 18 years of age or older

• Non-medical use of prescription drugs

• Any use of all marijuana

• Any use of all ecstasy

• Any use of all cocaine

• Any use of all crack cocaine

• Any use of all heroin

• Any use of all methamphetamine/crystal meth

• Motor vehicle crashes

• Crime

• Dependence or abuse

• Alcohol-related morbidity/mortality

• Tobacco-related morbidity/mortality

• Drug-related morbidity/mortality

• Other consumption pattern or consequence

• (Describe.)

• Other consumption pattern or consequence
  (Describe.)

2. When did you begin funding this prevention strategy? (Provide MM/YYYY.) ^{B, F (autofill at F)}

MM__________ YYYY ____________

3a. Have you completed implementation of this prevention strategy? ^{B, F (autofill at F)}

• Yes

• No (If selected, you will automatically proceed to Question 4.)

3b. Please specify the date the implementation of this prevention strategy was completed: ^{B, F (autofill at F)}

__________ MM/YYYY

4. Is this strategy part of a multi-strategy intervention? ^{B, F (autofilled based on db entry selection and locked)}

• Yes

• No, this is a single-strategy intervention

5. Is this an evidence-based program, policy or practice or a component of a multi-strategy evidence-based program, policy or practice? (Select one response.) ^{B, F (autofill at F)}

• Yes

• No (If selected, you will automatically proceed to Question 7.)

6. How did you know this is an evidence-based program, policy or practice or a component of one? (Select all that apply.) ^{B, F (autofill at F)}

• We did not use any specific criteria to determine that this was an evidence-based program, policy or practice

• Inclusion in a federal list or registry of evidence-based prevention interventions

• Found to be effective in a peer-reviewed journal

• Documentation of effectiveness based on the following guidelines:

a) Based on a solid theory or theoretical perspective that has been validated by research;

b) The prevention intervention is supported by a documented body of knowledge, generated from similar or related prevention interventions that indicate effectiveness;

c) The prevention intervention is judged by a consensus among informed experts to be effective based on a combination of theory, research and practice experience (informed experts may include key community prevention leaders, and elders or other respected leaders within indigenous cultures)

• Other (Describe.)

7. Which of the following best describes the implementation history of this prevention strategy? (Select one response.) ^{B, F (autofill at F)}

• Not implemented in the community prior to SPF SIG funding

• Continuation of a prevention intervention with no change

• Continuation of a prevention intervention with changes or adaptations

8. Does this prevention strategy include a curriculum or manual? By curriculum or manual, we mean a set of instructions about how to deliver the prevention intervention. This can be a pre-existing curriculum or manual created by the prevention intervention developer or a formal curriculum or manual developed by the community partner. (Select one response.) ^{B, F (autofill at F)}

• Yes

• No

For questions 9 through 13 below, indicate the areas being served by this prevention strategy and the estimated population of this area. You are required to include zip codes (question 11) for all areas being served by this prevention intervention. If your target population is the entire state you may enter ‘statewide’ for question 11. This is for purposes of reporting to the Center for Substance Abuse Prevention (CSAP). Use one line to describe each area. Other than zip code, you only need to complete those categories that are appropriate for your prevention intervention and community served. ^{B, F (autofill at F): items 8-12}

	9. City/Town	10. County/ Parish	11. Zip code(s)	12. Other geographic areas (Describe.)	13. What is the estimated population for the area described?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

14. What was the total cost of this prevention strategy during this reporting period–including planning, development, implementation, and evaluation? Make sure to include overhead and salary costs in the amount. If you do not know the exact amount spent, respond with the best numeric estimate. (Round to the nearest dollar. e.g., 36000). Do not use ‘$’ when entering your response. ^{B, F}

15. Approximately what percentage of total funding for this prevention intervention comes from SPF SIG funds? If you do not know the exact amount allocated, respond with your best estimate. This response should be written as a whole number. For example, if you received about a third of your funding for this prevention intervention from SPF SIG funds, respond with 33. Do not use ‘%’ when entering your response. ^{B, F}

Adaptations

This section asks for information about any adaptations you made to this evidence-based program, policy or practice. We understand that making adaptations to a prevention strategy can help make it more accessible to a specific population and we would like your honest answers about adaptations you may have made. Adaptations may include changes in target population, content, cultural appropriateness, dosage, duration, or setting of the prevention strategy that are different from those recommended by the prevention intervention developer.

16. Is this a new intervention developed and tested by you, the community partner? Some communities are funded to create new interventions for specific target populations, substances and consequences that have been identified as problem areas in the community. If your intervention is one you developed and have tested or are planning on testing with a target population select “yes.” (Select one response.) ^{B, F (autofill at F)}

• Yes (If selected, you will automatically proceed to Question 30.)

• No

17. Did you make any adaptations to the prevention strategy? ^{B, F (autofill at F)}

• Yes

• No (If selected, you will automatically proceed to Question 30.)

18. Did you adapt the prevention strategy in order to deliver it to a target population that was not indicated by the developer? (Examples of adaptations include, targeting an age group younger than the indicated target population or targeting pregnant teens as opposed to young adults ages 18-24 as indicated by the developer.) (Select one response.) ^{B, F}

• Yes

• No

• Prevention intervention developer makes no recommendations for target population

19. Did you make any adaptation to the curriculum or manual content of the prevention strategy? (Select one response.) ^{B, F}

• Yes

• No

• No curriculum or manual content specifications provided

20. Did you change the recommended dosage for this prevention strategy (e.g., the number of sessions or number of public service announcements (PSAs) or other media spots)? (Select one response.) ^{B, F}

• Yes

• No

• Prevention intervention developer makes no recommendations for dosage (If selected, you will automatically proceed to Question 23.)

21. Indicate the recommended dosage. (100 character limit.) ^{B, F (autofill at F)}

22. Indicate the dosage actually delivered. (100 character limit.) ^{B, F}

23. Did you adapt the recommended duration (e.g., days or hours) of this prevention intervention? (Select one response.) ^{B, F}

• Yes

• No

• Prevention intervention developer makes no recommendations for duration (If selected, you will automatically proceed to Question 26.)

24. Indicate the recommended duration, in hours, of this prevention intervention. This response should be written as a whole number (e.g., 4). ^{B, F (autofill at F)}

hours

25. Indicate the number of hours actually spent delivering the prevention intervention strategy. This response should be written as a whole number (e.g., 4). ^{B, F}

hours

26. Did you make an adaptation to the setting of the prevention intervention strategy (e.g., classroom, worksite, etc.)? (Select one response.) ^{B, F}

• Yes

• No

• Prevention intervention developer makes no recommendations for setting

27. Were any adaptations made to address the cultural appropriateness of the prevention intervention strategy for a particular group? (Select one response.) ^{B, F}

• Yes

• No

28. Did you collect information regarding participant satisfaction with the cultural appropriateness of the prevention intervention? (Select one response.) ^{B, F}

• Yes

• No (If selected, you will automatically proceed to Question 30.)

29. What were the results of the assessment of participants’ satisfaction with the cultural appropriateness of the prevention intervention? The results of an assessment of the cultural appropriateness of a prevention intervention will vary greatly. For this reason, we have included broad response options of highly satisfied, moderately satisfied, and not satisfied. We ask that you analyze the results of your particular assessment and choose the category that best corresponds to the overall results of your assessment. (Select one response.) B, F

• Participants were highly satisfied with cultural appropriateness.

• Participants were moderately satisfied with cultural appropriateness.

• Participants were not satisfied with cultural appropriateness.

• The number of participants who responded was too small, so it was impossible to adequately assess their satisfaction with the cultural appropriateness of the prevention intervention.

Prevention Intervention Outcomes

This section pertains to the collection of outcome data. Outcome data is information that reveals the extent of change in targeted attitudes, values, behaviors, or conditions between baseline measurement and subsequent points of measurement. Depending on the nature of the prevention intervention and the theory of change guiding it, changes can be immediate, intermediate, final, or longer-term outcomes.

If the evaluation for your prevention intervention strategy was conducted at the state/tribe/jurisdiction level, you may need to collaborate with the primary grantee organization (at the state/tribe/jurisdiction level) in order to complete questions 30 through 33.

30. Were any outcome data collected during this reporting period? This includes pretest, exit, and follow-up data, as well as other types of data. (Select one response.) ^{B, F}

• Yes

• No (If selected, you will automatically proceed to Question 34.)

31. What was your sampling strategy for collecting outcome data? (Select all that apply.) ^{B, F}

• The entire target population for the prevention intervention strategy

• Only the actual persons who directly participated in the prevention intervention strategy

• A specifically selected comparison group that did not receive the prevention intervention strategy

• Some other population or subgroup (Describe.)

32. Indicate the Center for Substance Abuse Prevention (CSAP) National Outcome Measures (NOMs) that were collected during this reporting period. (Select all that apply.) If completing the Web-based version of this instrument, click here to visit CSAP’s information about NOMs. (http://www.nationaloutcomemeasures.samhsa.gov/) ^{B, F}

• 30-day use

• Perceived risk of use

• Age of first use

• Perception of disapproval

• ATOD (Alcohol Tobacco and Other Drugs) suspensions/expulsions

• School attendance divided by enrollment (defined as attendance as a percentage of enrollment)

• Workplace ATOD (Alcohol Tobacco and Other Drugs) use

• Drug-related crime

• Alcohol-related car crashes and injuries

• Number of persons served by age, gender, race and ethnicity

• Total number of evidence-based programs, policies, or practices

• Cost efficiency for universal direct, universal indirect, selective, and indicated programs.

33. Was an analysis of outcome data completed during this reporting period? This analysis could have been completed by the community partner, the state/tribe/jurisdiction, or some other entity. In addition, this analysis could have been conducted by someone paid through the SPF SIG funds, or someone who was providing their services free-of-charge or as an in-kind contribution. (Select one response.) ^{B, F}

• Yes

• No

Closing Question

34. Provide any additional comments about your prevention intervention activities here. (Provide a concise written description in the space available.) (3000 character limit.) ^{B, F}

Prevention Education Sub-Form

35. When did you first start serving participants with this Prevention Education intervention strategy, including all cycles? (Provide MM/YYYY.) ^{B, F (autofill at F)}

__________ MM/YYYY

36. Is this a recurring prevention intervention strategy, in which the same group of people are served over multiple sessions? An example would be a prevention intervention that is delivered to the same group of participants every Monday night for 6 weeks, or to an 8^th grade health class every Friday in a semester. (Select one response.) ^{B, F (autofill at F)}

• Yes

• No

37. Is this prevention intervention strategy implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year? If your prevention intervention takes place for a period of time with the same participants and then starts over with new participants, select “yes.” A prevention intervention strategy can be both recurring and implemented in a series of cycles. (Select one response.) ^{B, F (autofill at F)}

• Yes

• No (If selected, you will automatically proceed to Question 38.)

37a. What are the cycles based on? (Select one response.)

The school calendar (quarters, semesters, school year)

 The SPF SIG funding cycle

 An organizational fiscal cycle

 Other (Describe.)

38. As delivered, how would you classify this prevention intervention strategy according to the Institute of Medicine categories? (Select one response.) ^{B, F (autofill at F)}

• Universal Direct

• Universal Indirect

• Selective

• Indicated

39. What was the format of the prevention education intervention strategy during this reporting period? (Select all that apply.) ^{B, F}

• Individual

• Small group (2-9)

• Large group (10-49)

• Extra large group (50+)

• Web-based

• Other (Describe.)

40. Indicate the types of participants served by this prevention intervention strategy during this reporting period. (Select all that apply.) ^{B, F}

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Adults age 21 and older

• Parents

• Community leaders

• Healthcare providers

• Substance abuse prevention/treatment workers

• Law enforcement

• Other (Describe.)

41. How many groups of participants started the prevention education intervention strategy during this reporting period? Do not include groups counted in previous reporting periods. This response should be written as a whole number (e.g., 4). ^{B, F}

42. How many groups of participants completed the prevention education intervention strategy during this reporting period? Do not include groups counted in previous reporting periods. This response should be written as a whole number (e.g., 4). ^{B, F}

43. What was the total number of sessions provided for all groups of participants in the prevention education intervention strategy during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

44. What was the average length of the individual sessions, in hours, during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

hours

45. How many new participants were served by this prevention strategy during this reporting period? New participants are participants who had not received or participated in the prevention intervention before and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4).

__________ (If none, enter ‘0’—you will automatically proceed to the end of this sub-form) ^{B, F}

46. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 45), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of new participants reported in question 45. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

46a. Number of females:_____________

46b. Number of males:______________

46c. Gender Unknown:______________

47. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 45), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in question 45. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

46a. Children age 0 to 11:_____________

46b. Youth age 12 to 17:_____________

46c. Young adults age 18 to 20:_____________

46d. Young adults age 21-25: ______________

46e. Adults age 26 and older_____________

46f. Age Unknown:___________

48. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 45), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of AI/AN, Asians, Black, PI, White, Multiracial, Other, and unknown should add up to the total of new participants reported in question 45. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

48a. American Indian/Alaska Native:_____________

48b. Asian:_____________

48c. Black or African American:_____________

48d. Native Hawaiian or Other Pacific Islander: ______________

48e. White _____________

48f. Multiracial:___________

48g. Other: _____________

48h. Race Unknown: ___________

49. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 45), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of new participants reported in question 45. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

49a. Hispanic/Latino ____________

49b. Non-Hispanic/Latino ____________

49c. Hispanic Ethnicity Unknown ____________

Alternative Drug-Free Activities Sub-Form

50. When did you first start serving participants with this Alternative Drug-Free Activities prevention intervention strategy, including all cycles? (Provide MM/YYYY.) ^{B, F (autofill at F)}

_______ MM/YYYY

51. Are the alternative drug-free activities targeted at a specific group, such as high school students, college students, etc? ^{B, F (autofill at F)}

• Yes

• No ((If selected, you will automatically proceed to Question 66)

52. Are these recurring activities, in which the same group of people is served over multiple prevention intervention strategy sessions? (Select one response.) ^{B, F (autofill at F)}

• Yes

• No

53. Is this prevention intervention strategy implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year? (Select one response.) ^{B, F (autofill at F)}

• Yes

• No (If selected, you will automatically proceed to Question 54.)

53a. What are the cycles based on? (Select one response.)

 The school calendar (quarters, semesters, school year)

•  The SPF SIG funding cycle

•  An organizational fiscal cycle

•  Other (Describe.)

54. As delivered, how would you classify this prevention intervention strategy according to the Institute of Medicine categories? (Select one response.) ^{B, F (autofill at F)}

• Universal Direct

• Universal Indirect

• Selective

• Indicated

55. What was the format of the alternative drug-free activities prevention intervention strategy during this reporting period? (Select all that apply.) ^{B, F}

• Individual

• Small group (2-9)

• Large group (10-49)

• Extra large group (50+)

• Web-based

• Other (Describe.)

56. Indicate the types of participants served by this prevention intervention strategy during this reporting period. (Select all that apply.) ^{B, F}

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Adults age 21 and older

• Parents

• Community leaders

• Healthcare providers

• Substance abuse prevention/treatment workers

• Law enforcement

• Other (Describe.)

57. How many groups of participants started the alternative drug-free activities prevention intervention strategy during this reporting period? Do not include groups counted in previous reporting periods. This response should be written as a whole number (e.g., 4). ^{B, F}

58. How many groups of participants completed the alternative drug-free activities prevention intervention strategy during this reporting period? Do not include groups counted in previous reporting periods. This response should be written as a whole number (e.g., 4). ^{B, F}

59. What was the total number of sessions provided for all groups of participants in the alternative drug-free activities prevention intervention strategy during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

60. What was the total number of hours provided for all groups of participants in the alternative drug-free activities prevention intervention strategy during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

hours

61. How many new participants were served by this prevention intervention strategy during this reporting period? New participants are participants who had not received or participated in the prevention intervention before and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4). ^{B, F}

_____________ (If none, enter ‘0’—you will automatically proceed to the end of this subform.)

62. Of the total number of new participants served by this prevention intervention strategy during this reporting period (reported in question 61), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of new participants reported in question 61. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

62a. Number of females:_____________

62b. Number of males:______________

62c. Don’t know/Other:_______________

63. Of the total number of new participants served by this prevention intervention strategy during this reporting period (reported in question 61), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in question 61. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

63a. Children age 0 to 11:_____________

63b. Youth age 12 to 17:_____________

63c. Young adults age 18 to 20:_____________

63d. Adults age 21 and older:_____________

63e. Don’t know:_____________

64. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 61), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of AI/AN, Asians, Black, PI, White, Multiracial, Other, and unknown should add up to the total of new participants reported in question 61. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

64a. American Indian/Alaska Native:_____________

64b. Asian:_____________

64c. Black or African American:_____________

64d. Native Hawaiian or Other Pacific Islander: ______________

64e. White _____________

64f. Multiracial:___________

64g. Other: _____________

64h. Race Unknown: ___________

65. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 61), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of new participants reported in question 61. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

65a. Hispanic/Latino ____________

65b. Non-Hispanic/Latino ____________

65c. Hispanic Ethnicity Unknown ____________

66. Did you conduct drug-free events (concerts, festivals/fairs, picnics, sporting events) during this reporting period that were not targeted to specific groups of participants? (Select one response.) ^{B, F}

• Yes

• No (If no, skip to question 69.)

67. How many drug-free events were conducted during this reporting period? This response should be written as a whole number (e.g., 4) ^{B, F}.

68. How many people were reached through the drug-free events during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

Problem Identification and Referral Sub-Form

69. When did you first start serving participants with this Problem Identification and Referral prevention intervention strategy, including all cycles? (Provide MM//YYYY.) ^{B, F (autofill at F)}

_________ MM//YYYY

70. Indicate the types of participants served by the Problem Identification and Referral prevention intervention strategy during this reporting period. (Select all that apply.) ^{B, F}

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Adults age 21 and older

• Parents

• Community leaders

• Healthcare providers

• Substance abuse prevention/treatment workers

• Law enforcement

• Other (Describe.) ________________________________________________

71. What was the total number of individuals for whom problem identification and referral services were provided during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

72. Where did problem identification and referral activities take place during this reporting period? (Select all that apply.) ^{B, F}

• School

• Health care facilities

• Jails or prisons

• Courts

• Other (Describe.)

73. What type of services were individuals referred to during this reporting period? (Select all that apply.) ^{B, F}

• Substance abuse treatment

• Mental health treatment

• Substance abuse prevention activities

• Housing services

• After school activities

• Transportation

• Day care or adult care services

• Other (Describe.)

74. How many new participants were served by this prevention intervention during this reporting period? New participants are participants who had not received or participated in the prevention intervention before and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4). ^{B, F}

_____________ (If none, enter ‘0’ —you will automatically proceed to the end of this sub-form).

75. Of the total number of new participants served by this prevention intervention strategy during this reporting period (reported in question 74), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of new participants reported in question 74. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

75a. Number of females:_____________

75b. Number of males:______________

75c. Don’t know/Other:_______________

76. Of the total number of new participants served by this prevention intervention strategy during this reporting period (reported in question 74), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in question 74. This response should be written as a whole number (e.g., 4) and not expressed as a percentage ^{B, F}.

76a. Children age 0 to 11:_____________

76b. Youth age 12 to 17:_____________

76c. Young adults age 18 to 20:_____________

76d. Young adults age 21 and older:_____________

76e. Don’t know:______________

77. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 74), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of AI/AN, Asians, Black, PI, White, Multiracial, Other, and unknown should add up to the total of new participants reported in question 74. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

77a. American Indian/Alaska Native:_____________

77b. Asian:_____________

77c. Black or African American:_____________

77d. Native Hawaiian or Other Pacific Islander: ______________

77e. White _____________

77f. Multiracial:___________

77g. Other: _____________

77h. Race Unknown: ___________

78. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 74), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of new participants reported in question 74. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

78a. Hispanic/Latino ____________

78b. Non-Hispanic/Latino ____________

78c. Hispanic Ethnicity Unknown ____________

Community-Based Processes Sub-Form

79. Did you do any work related to task forces of coalitions during this reporting period? ^{B, F}

• Yes

• No (if selected you will automatically proceed to Question 83)

80. Indicate the number of task force/coalition members you recruited during this reporting period, if any. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.’)

81. Indicate the number of task force/coalition meetings you held during this reporting period, if any. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.’)

82. Indicate the number of task force/coalition members you trained during this reporting period, if any. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.’)

83. Indicate the number of community members, other than task force or coalition members, you trained during this reporting period, if any. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.’)

84. Did you coordinate funding with other organizations/projects during this reporting period? (Select one response.) ^{B, F}

• Yes

• No

85. Did you develop prevention or provider networks during this reporting period? (Select one response.) ^{B, F}

• Yes

• No

86. Indicate how many community outreach/education sessions you hosted during this reporting period, if any. Do not include outreach or education sessions that are counted or reported in another section of this instrument. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.’)

87, Indicate the number of community organizations to whom you provided funding or other in-kind donations during this reporting period, if any. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.—you will automatically proceed to Question 89)

88. How much funding did you provide to community organizations during this reporting period? (Include in-kind donations.). This response should be rounded to the nearest dollar (e.g., 36,000). ^{B, F}

(If none, enter ‘0.’)

89. Indicate the number of community organizations to whom you provided technical assistance during this reporting period, if any. This response should be written as a whole number (e.g., 4). ^{B, F}

(If none, enter ‘0.’)

90. Did you reorganize local agencies to promote efficiency in delivering substance abuse prevention during this reporting period? (Select one response.) ^{B, F}

• Yes

• No

91. Did you reallocate local funds for substance abuse prevention during this reporting period? (Select one response.) ^{B, F}

• Yes

• No

92. Did you formally change the ways local organizations work together to address substance abuse prevention during this reporting period, for example by officially changing school curricula or by documenting specific policies or practices for working together? (Select one response.) ^{B, F}

• Yes

• No

93. Did you monitor regulatory or compliance changes by the state/tribe/jurisdiction toward local or regional organizations during this reporting period? (Select one response.) ^{B, F}

• Yes

• No

94. Did you conduct other community activities during this reporting period? (Select one response.) ^{B, F}

 Yes (Describe.)

 No

95. How often did you conduct other community activities during this reporting period? ^{B, F}

96. Provide an estimate of the total number of individuals who received or were affected by this prevention strategy during this reporting period. If you are unsure of the exact number of individuals affected respond with your best estimate. ^{B, F}

___________________

97. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by gender. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

97a. Percent Female:_____________

97b. Percent Male:_____________

97c. Percent Gender Unknown:_____________

98. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by age group. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

98a. Percent Children age 0 to 11:_____________

98b. Percent Youth age 12 to 17:_____________

98c. Percent Young Adults age 18 to 20:_________

98d. Percent Young Adults age 21-25: ______________

98e. Percent Adults age 26 and older_____________

98f. Percent Age Unknown:___________

99. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by racial group. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

99a. Percent American Indian/Alaska Native:_____________

99b. Percent Asian:_____________

99c. Percent Black or African American:_____________

99d. Percent Native Hawaiian or Other Pacific Islander: ______________

99e. Percent White _____________

99f. Percent Multiracial:___________

99g. Percent Other: _____________

99h. Percent Race Unknown: ___________

100. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by Hispanic/Latino ethnicity. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

100a. Percent Hispanic/Latino ____________

100b. Percent Non-Hispanic/Latino ____________

100c. Percent Hispanic Ethnicity Unknown ____________

Environmental Strategies Sub-Form

101. When did you first start conducting the environmental strategy? (Provide MM/YYYY.) ^{B, F (autofill at F)}

___________ MM /YYYY

102. What type of environmental strategy was conducted? ^{B, F}

• Policy enactment, establishment, or implementation

• Enforcement (e.g., sobriety checkpoints, neighborhood surveillance, building inspections)

• Communication (e.g., social marketing, media literacy)

103. What individuals or organizations did you work with in planning or implementing the environmental strategy during this reporting period? (Select all that apply.) ^{B, F}

• Youth

• Parents

• Business community

• Media (e.g., radio and television stations, newspapers and magazines)

• School(s)

• Youth serving organization(s) (other than schools) (e.g., Big Brothers Big Sisters, Boy Scouts/Girl Scouts)

• Law enforcement agency/agencies

• Religious or fraternal organization(s) (e.g., churches, Lions Club, Kiwanis)

• Civic or volunteer organization(s) (e.g., local sports associations, neighborhood associations)

• Healthcare professionals

• State and/or local and/or jurisdictional or tribal government agencies

• Other (Describe.)_____________________________________________________

104. Provide an estimate of the total number of individuals who received or were affected by the prevention intervention strategy during this reporting period. If you are unsure of the exact number of individuals affected respond with your best estimate. ^{B, F}

__________

105. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by gender. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

105a. Percent Female:_____________

105b. Percent Male:_____________

105c. Percent Gender Unknown:_____________

106. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by age group. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

106a. Percent Children age 0 to 11:_____________

106b. Percent Youth age 12 to 17:_____________

106c. Percent Young Adults age 18 to 20:_________

106d. Percent Young Adults age 21-25: ______________

106e. Percent Adults age 26 and older_____________

106f. Percent Age Unknown:___________

107. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by racial group. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

107a. Percent American Indian/Alaska Native:_____________

107b. Percent Asian:_____________

107c. Percent Black or African American:_____________

107d. Percent Native Hawaiian or Other Pacific Islander: ______________

107e. Percent White _____________

107f. Percent Multiracial:___________

107g. Percent Other: _____________

107h. Percent Race Unknown: ___________

108. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by Hispanic/Latino ethnicity. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

108a. Percent Hispanic/Latino ____________

108b. Percent Non-Hispanic/Latino ____________

108c. Percent Hispanic Ethnicity Unknown ____________

Information Dissemination Sub-Form

109. When did you first start conducting information dissemination activities as part of this prevention intervention? Do not include activities or information that you have reported in other areas, such as the environmental strategies section. (Provide MM/YYYY.) ^{B, F (autofill at F)}

_________ MM/YYYY

110. What individuals or organizations did you work with in planning or implementing your information dissemination efforts during this reporting period? (Select all that apply.) ^{B, F}

• Youth

• Parents

• Business community

• Media (e.g., radio and television stations, newspapers and magazines)

• School(s)

• Youth serving organization(s) (other than schools) (e.g., Big Brothers Big Sisters, Boy Scouts/Girl Scouts)

• Law enforcement agency/agencies

• Religious or fraternal organization(s) (e.g., churches, Lions Club, Kiwanis)

• Civic or volunteer organization(s) (e.g., local sports associations, neighborhood associations)

• Healthcare professionals

• State and/or local and/or tribal government agencies

• Other (Describe.)_____________________________________________________

111. What types of information did you disseminate? (Select all that apply.) ^{B, F}

•  Program information (e.g., contact information, meeting times, etc.)

• Substance abuse prevention information

• Surveillance and monitoring information, for example information about whom to contact if you suspect a meth lab is operating in your neighborhood.

• Drunk driving prevention information, such as free cab rides home on New Years Eve

• Other (Describe.)________________________________________

112. What format was the information you disseminated? (Select all that apply.) ^{B, F}

• Brochures

• Flyers

• Magnets

• Other promotional items (Frisbees, balls, cups)

• Other (Describe.)________________________________________

113. Describe the settings in which the information was disseminated. For example, the information may have been disseminated at a Parent Teacher Association meeting, a rock concert, a parade, etc. (500 character limit.) ^{B, F}

___________________

114. Approximately how many individuals received the information disseminated during this reporting period? This response should be written as a whole number (e.g., 4). If you are unsure of the exact number of individuals affected respond with your best estimate ^{B, F}

______________

115. Provide an estimate of the total number of individuals who received or were affected by this prevention intervention. This response should be written as a whole number (e.g., 4).If you are unsure of the exact number of individuals affected respond with your best estimate ^{B, F}

__________

116. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by gender. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

116a. Percent Female:_____________

116b. Percent Male:_____________

116c. Percent Gender Unknown:_____________

117. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by age group. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

117a. Percent Children age 0 to 11:_____________

117b. Percent Youth age 12 to 17:_____________

117c. Percent Young Adults age 18 to 20:_________

117d. Percent Young Adults age 21-25: ______________

117e. Percent Adults age 26 and older_____________

117f. Percent Age Unknown:___________

118. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by racial group. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

118a. Percent American Indian/Alaska Native:_____________

118b. Percent Asian:_____________

118c. Percent Black or African American:_____________

118d. Percent Native Hawaiian or Other Pacific Islander: ______________

118e. Percent White _____________

118f. Percent Multiracial:___________

118g. Percent Other: _____________

118h. Percent Race Unknown: ___________

119. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by Hispanic/Latino ethnicity. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

119a. Percent Hispanic/Latino ____________

119b. Percent Non-Hispanic/Latino ____________

119c. Percent Hispanic Ethnicity Unknown ____________

Other Activities or Services Delivered to Individuals Sub-Form

120. Describe any prevention intervention strategy, other than prevention education, alternative drug-free activities or problem identification and referral strategies, that was delivered to individuals during this reporting period. (3000 character limit.) ^{B, F (autofill at F)}

121. When did you first start conducting this prevention intervention strategy? (Provide MM/YYYY.) ^{B, F (autofill at F)}

______ MM/YYYY

122. As delivered, how would you classify this prevention intervention strategy according to the Institute of Medicine categories? (Select one response.) ^{B, F (autofill at F)}

• Universal Direct

• Universal Indirect

• Selective

• Indicated

123. What was the format of this prevention intervention strategy during this reporting period? (Select all that apply.) ^{B, F}

• Individual

• Small group (2-9)

• Large group (10-49)

• Extra large group (50+)

• Web-based

• Other (Describe.)

124. Indicate the types of participants served by this strategy during this reporting period. (Select all that apply.) ^{B, F}

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Adults age 21 and older

• Parents

• Community leaders

• Healthcare providers

• Substance abuse prevention/treatment workers

• Law enforcement

• Other (Describe.) ________________________________________________

125. How many sessions did you conduct during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

126. What was the average duration of one session during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

hours

127. How many new participants were served by this prevention strategy during this reporting period? New participants are participants who had not received or participated in the prevention intervention before and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4). ^{B, F}

_____________ (If none, enter ‘0’—you will automatically proceed to the end of this sub-form)

128. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 127), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of new participants reported in question 127. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

128a. Number of females:_____________

128b. Number of males:______________

128c. Gender Unknown:______________

129. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 127), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in question 127. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

129a. Children age 0 to 11:_____________

129b. Youth age 12 to 17:_____________

129c. Young adults age 18 to 20:_____________

129d. Young adults age 21-25: ______________

129e. Adults age 26 and older_____________

129f. Age Unknown:___________

130. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 127), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of AI/AN, Asians, Black, PI, White, Multiracial, Other, and unknown should add up to the total of new participants reported in question 127. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

130a. American Indian/Alaska Native:_____________

130b. Asian:_____________

130c. Black or African American:_____________

130d. Native Hawaiian or Other Pacific Islander: ______________

130e. White _____________

130f. Multiracial:___________

130g. Other: _____________

130h. Race Unknown: ___________

131. Of the total number of new participants served by this prevention strategy during this reporting period (reported in question 127), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of new participants reported in question 127. This response should be written as a whole number (e.g., 4) and not expressed as a percentage. ^{B, F}

131a. Hispanic/Latino ____________

131b. Non-Hispanic/Latino ____________

131c. Hispanic Ethnicity Unknown ____________

Other Activities or Services Not Delivered to Individuals Sub-Form

132. Describe the activities or services you provided during this reporting period, other than community-based processes, environmental strategies, or information dissemination to implement your prevention intervention, that were not delivered to individuals. Make sure to include reports of any counts or frequencies, as they apply. (3000 character limit.) ^{B, F (autofill at F)}

133. Describe the intended target population for these activities or services. (3000 character limit.) ^{B, F (autofill at F)}

134. When did you first start conducting these other non-participant based activities, as a prevention intervention strategy? (Provide MM/YYYY.) ^{B, F (autofill at F)}

__________ MM/YYYY

135. Provide an estimate of the total number of individuals who received or were affected by this prevention strategy during this reporting period. If you are unsure of the exact number of individuals affected respond with your best estimate. ^{B, F}

___________________

136. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by gender. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

136a. Percent Female:_____________

136b. Percent Male:_____________

136c. Percent Gender Unknown:_____________

137. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by age group. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

137a. Percent Children age 0 to 11:_____________G

137b. Percent Youth age 12 to 17:_____________

137c. Percent Young Adults age 18 to 20:_________

137d. Percent Young Adults age 21-25: ______________

137e. Percent Adults age 26 and older_____________

137f. Percent Age Unknown:___________

138. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by racial group. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

138a. Percent American Indian/Alaska Native:_____________

138b. Percent Asian:_____________

138c. Percent Black or African American:_____________

138d. Percent Native Hawaiian or Other Pacific Islander: ______________

138e. Percent White _____________

138f. Percent Multiracial:___________

138g. Percent Other: _____________

138h. Percent Race Unknown: ___________

139. Provide an estimate of the percentage of individuals who received or were affected by this prevention strategy by Hispanic/Latino ethnicity. This percentage should be written as a whole number (e.g., 20) and the sum of all responses should equal 100%. Do not use ‘%’ when entering your response. ^{B, F}

139a. Percent Hispanic/Latino ____________

139b. Percent Non-Hispanic/Latino ____________

139c. Percent Hispanic Ethnicity Unknown ____________

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