A1c SPFSIGI_IICLIP A1c SPFSIGI_IICLIPart2

ATTACHMENT A1c: SPF SIG I & II CLI Part 2

Form Approved

OMB No. XXXX-XXXX

Expiration Date XX/XX/XXXX

Strategic Prevention Framework

State Incentive Grant

(SPF SIG)

Cohorts I & II

Cross-Site Evaluation

Community Level Instrument

(Part II):

Intervention Strategies

March 2006

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 XX hours 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 XXXX-XXXX.

SPF SIG Cross-Site Evaluation, Community Level Instrument, Part II

Intervention Form 3

Information and Directions 3

Intervention Information 4

Adaptations 9

Intervention Outcomes 12

Closing Question 13

Prevention Education Sub-Form 14

Alternative Drug-Free Activities Sub-Form 18

Problem Identification and Referral Sub-Form 22

Community-Based Processes Sub-Form 25

Environmental Strategies Sub-Form 29

Information Dissemination Sub-Form 44

Other Activities or Services Delivered to Individuals Sub-Form 47

Other Activities or Services Not Delivered to Individuals Sub-Form 51

Intervention Form

Information and Directions

This instrument is designed to collect information about the activities of the community partners for the Strategic Prevention Framework -State Incentive Grant (SPF-SIG) Initiative. This information will be collected every 6 months, with a select number of questions being asked only once throughout the life of the grant.

The CLI is designed as a two-part survey. Part I collects data about the community’s progress through the strategic prevention framework. Part II collects information about the specific intervention(s) being implemented by the community. The community will complete a separate Part II form for each intervention implemented. For example, if the community is implementing both a participant-based, education intervention and an environmental intervention, they will complete two Part II forms. 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. Each community partner will be assigned a unique numerical identification. This identification will be used to ensure that communities cannot be identified. In addition, no individuals will be identified in the reporting of results.

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

Directions for skipping questions are indicated where appropriate to minimize the time needed to complete the questionnaire. This web-based survey is designed to automatically take you to the appropriate question, but you should still follow the directions closely.

Throughout this instrument, words that are underlined are hyperlinked to a list of definitions. In addition, if you click here you can access SAMHSA’s prevention glossary as well. (https://preventionplatform.samhsa.gov/MacroHQ/Glossary2/dssglossary.cfm?sect_id=1&topic_id=99&CFID=2112072&CFTOKEN=48724502)

Throughout this document, the term “you” refers to the community partner that has received SPF SIG funding from the state. This could be an organization, coalition, or other entity. If this community partner is a community coalition, the Project Director for the SPF SIG 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. Each section of the instrument includes a list of individuals whom you may want to consider asking to assist you in this data collection process. 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.

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 narrative response questions in a word processor and copy and paste them into the web-based survey.

I

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

• Project Director

• Project Coordinator

• Intervention delivery staff

• Evaluator

• Coalition representative(s)

f you need assistance in completing this instrument, contact Shelly Kowalczyk at (301) 587-1600 or via e-mail at [email protected]

Intervention Information

1. Name of the intervention

________________________________________

2. When did you begin funding this intervention? (Provide MM/YYYY.)

MM/YYYY ____________

3. When did you complete implementing this intervention? If you are currently implementing this intervention, leave this response blank. (Provide MM/YYYY)

MM/YYYY ____________

4. What factors, beyond data driven planning, influenced your intervention selection? (Select all that apply.)

 Local capacity to deliver interventions

 Cost

 Experience implementing intervention prior to SPF SIG funding

 Political environment

 Requirements of partnering organizations

 Evidence-based literature on effectiveness

 Other information supporting the effectiveness of the intervention

 Demographics or cultural characteristics of local population

 Availability of technical assistance

 Recommendation by state funding agency

 Other (Describe.)

5. Is this an evidence-based program, policy or practice ? (Select yes or no.)

 Yes

 No (If no, proceed to question 7.)

6. How do you know this is an evidence-based program, policy or practice ? (Select all that apply.)

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

 Evaluator recommendation

 Listed in National Registry of Effective Programs and Practices (NREPP)

 Listed on some other federal agency or national organization’s list of “effective programs”

 Found to be effective in a peer-reviewed journal article

 Based on a theory or conceptual model

 Implemented in a similar community

 CSAP recommendation

 Center for the Application of Prevention Technologies (CAPT) Web site

 Other (Describe.)

7. 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 yes or no.)

 Yes

 No (If no, proceed to question 10.)

8. If the intervention you are developing is based on an evidence-based program, policy or practice , provide the name of that intervention. If you do not know the full name of the intervention, provide the name you use. For example, you may have developed a new intervention, but used Life Skills Training as a starting point for your newly designed intervention. Provide as much information as necessary for clarification.

9. Indicate why you decided to develop a new intervention rather than using a previously tested intervention. (Select all that apply.)

 Previously tested interventions did not address the need in our community

 Previously tested interventions were not culturally appropriate

 Previously tested interventions were too costly

 Other (Describe.)

10. Which of the following best describes this intervention? (Select one response.)

 Not implemented in the community prior to SPF SIG funding (If marked, proceed to question 12.)

 Continuation of an intervention with no change (If marked, proceed to question 12.)

 Continuation of an intervention with changes or adaptations

11. If the intervention is the continuation of an intervention with changes or adaptations, describe the changes or adaptations and the reasons for the changes.

12. Is your definition of community based on something other than geography, such as a target population? (Select yes or no.)

 Yes (If yes, proceed to question 18.)

 No

For questions 13 through 17 below, indicate the areas being served by this intervention and the estimated population of this area. Use one line to describe each area. You only need to complete those categories that are appropriate for your intervention and community served. For example, if you are implementing a countywide environmental intervention, it makes sense to provide the name of the county, but it would not make sense to list all of the zip codes that are in that county. On the other hand, if you are implementing a neighborhood-based intervention, you would list the zip codes of the area being served.

City/Town	County/ Parish	Zip code(s)	Other geographic areas, including statewide (Describe.)	What is the estimated population for the area described?
a.
b.
c.

18. Of the total SPF SIG funding you received, what was the amount spent on this entire intervention--including planning, developing, implementing and evaluating the intervention--during this reporting period? 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.)

$____________

19. Approximately what percentage of total funding for this intervention comes from SPF SIG funds? If you do not know the exact amount allocated, respond with your best numeric estimate. For example, if you received about a third of your funding for this intervention from SPF SIG funds, respond with 33%.

_______ %

20. Indicate the CSAP domain this intervention targets: (Select all that apply.)

For more information on CSAP’s domains, visit the Web site listed here:

http://www.northeastcapt.org/science/pod/agencyInfo.asp?caller=

 Individual domain

 Family domain

 Peer domain

 School domain

 Community domain

 Society/Environmental domain

21. Indicate the component(s) that are included in this intervention. Interventions may employ several different components: (Select all that apply.)

 Prevention education)

 Alternative drug-free activities

 Problem identification and referral

 Community based processes

 Environmental strategies

 Information dissemination

 Other activities or services delivered to individuals (Describe.)_____________________

 Other activities or services not delivered to individuals (Describe.)_______________

22. Does this intervention include a curriculum or manual ? By curriculum or manual, we mean a set of instructions about how to deliver the intervention. This can be a pre-existing curriculum or manual created by the intervention developer or a formal curriculum or manual developed by the community partner. (Select yes or no.)

 Yes

 No

23. Have any individual participants been served by this intervention during this reporting period, for example in classroom-based interventions or other direct service interventions? (Select yes or no.)

 Yes

 No (If no, proceed to next section, Adaptations.)

24. How many new participants were served by this intervention during this reporting period? New participants are participants who had not received or participated in the intervention before and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best numeric estimate.

_____________

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 an intervention 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 intervention that are different from those recommended by the intervention developer.

25. Did you adapt the intervention 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 young men having sex with men as opposed to young adults ages 18-24 as indicated by the developer.) (Select one response.)

 Yes

 No (If no, proceed to question 27.)

 Intervention developer makes no recommendations for target population (If marked, proceed to question 27.)

 Not applicable (If not applicable, proceed to question 27.)

26. Describe the adaptation you made in order to deliver the intervention to a target population that was not indicated by the developer. (Provide a concise written description in the space available.)

27. Did you make any adaptation to the curriculum or manual content of the intervention? (Select one response.)

 Yes

 No (If no, proceed to question 29.)

 Intervention developer makes no recommendations for curriculum or manual content (If marked, proceed to question 29.)

 Not applicable (If not applicable, proceed to question 29.)

28. Describe the adaptation made to the curriculum or manual content. (Provide a concise written description in the space available.)

29. Did you make any adaptations to address the cultural appropriateness of the intervention for a particular group? (Select one response.)

 Yes

 No (If no, proceed to question 31.)

 Intervention developer makes no recommendations regarding the cultural appropriateness of the intervention for different groups (If marked, proceed to question 31.)

 Not applicable (If not applicable, proceed to question 31.)

30. Describe the changes you made to improve the cultural appropriateness of the intervention and how the fit was improved for a particular group. (Provide a concise written description in the space available.)

31. Did you adapt the recommended dosage for this intervention (e.g., the number of sessions or number of public service announcements (PSAs) or other media spots)? (Select one response.)

 Yes

 No (If no, proceed to question 34.)

 Intervention developer makes no recommendations for dosage (If marked, proceed to question 34.)

 Not applicable (If not applicable, proceed to question 34.)

32. Indicate the recommended dosage.

33. Indicate the dosage actually delivered.

34. Did you adapt the recommended duration (e.g., days or hours) of this intervention? (Select one response.)

 Yes

 No (If no, proceed to question 37.)

 Intervention developer makes no recommendations for duration (If marked, proceed to question 37.)

 Not applicable (If not applicable, proceed to question 37.)

35. Indicate the recommended duration, in hours, of this intervention.

hours

36. Indicate the number of hours actually spent delivering the intervention.

hours

37. Did you make an adaptation to the setting of the intervention (e.g., classroom, worksite, etc.)? (Select one response.)

 Yes

 No (If no, proceed to question 39.)

 Intervention developer makes no recommendations for setting (If marked, proceed to question 39.)

 Not applicable (If not applicable, proceed to question 39.)

38. Describe the adaptation made to the setting of the intervention (e.g., classroom, worksite, etc.). (Provide a concise written description in the space available.)

39. Did you collect information regarding participant satisfaction with the cultural appropriateness of the intervention? (Select yes or no.)

 Yes

 No (If no, proceed to next section, Intervention Outcomes.)

40. What were the results of the assessment of participants’ satisfaction with the cultural appropriateness of the intervention? The results of an assessment of the cultural appropriateness of an 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.)

 Participants were highly satisfied with cultural appropriateness.

 Participants were moderately satisfied with cultural appropriateness.

 Participants were not satisfied with cultural appropriateness.

 Not enough participants responded to adequately assess their satisfaction with the cultural appropriateness of the intervention.

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 intervention and the theory of change guiding it, changes can be immediate, intermediate, final, or longer-term outcomes.

If your intervention evaluation was conducted at the state level, questions 41 through 44 will be completed by the state.

41. 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 yes or no.)

 Yes

 No (If no, proceed to question 45.)

42. If outcome data were collected, what was your sampling strategy? (Select all that apply.)

 The entire target population for the intervention

 Only the actual persons who directly participated in the intervention

 A specifically selected comparison group that did not receive the intervention

 Some other population or subgroup (Describe.)

43. Indicate the CSAP National Outcome Measures (NOMs) that are being collected. (Select all that apply.) If completing the Web-based version of this instrument, click here to visit CSAP’s information about NOMs.

 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 interventions

 Increased services provided within cost bands for universal , selective , and indicated programs.

44. Was an analysis of outcome data completed during this reporting period? This analysis could have been completed by the community partner, the state, 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 yes or no.)

 Yes

 No

Closing Question

45. Provide any additional comments about your prevention intervention activities here. (Provide a concise written description in the space available.)

Prevention Education Sub-Form

46. When did you first start serving participants with this Prevention Education component of the intervention, including all cycles? (Provide MM/YYYY.)

MM/YYYY ____________

47. Is this a recurring intervention, in which the same group of people are served over multiple intervention sessions? An example would be an 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 yes or no.)

 Yes

 No

48. Is the prevention education component of this intervention 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 intervention takes place for a period of time with the same participants and then starts over with new participants, select “yes.” An intervention can be both recurring (question 47) and implemented in a series of cycles (question 48). (Select yes or no.)

 Yes

 No (If no, proceed to question 50.)

49. If the prevention education component of the intervention is implemented in cycles, 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.)

50. How many new groups of participants started the prevention education component of the intervention during this reporting period?

51. How many new groups of participants completed the prevention education component of the intervention during this reporting period?

52. What was the total number of sessions provided for each group of participants in the prevention education component of the intervention during this reporting period?

53. What was the average length of the individual sessions, in hours, during this reporting period?

hours

54. What was the format of the prevention education component of the intervention during this reporting period? (Select all that apply.)

 Individual

 Small group (2-9)

 Large group (10-49)

 Extra large group (50+)

 Web-based

 Other (Describe.)

55. Indicate the types of participants served by the prevention education component of the intervention during this reporting period. (Select all that apply.)

 Children age 0 to 3

 Children age 4 to 5

 Children age 6 to 11

 Youth age 12 to 17

 Young adults age 18 to 20

 Young adults age 21 to 24

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

56. As delivered, how would you classify this Prevention Education component according to the Institute of Medicine categories? (Select one response.)

 Universal

 Selective

 Indicated

Use the table below to indicate the percentage of participants of each race served during the reporting period. Include all participants who were served by the prevention education component of this intervention during this reporting period.

If you do not know exact percentages of each race served, you may estimate percentages by determining the percentage of various races throughout the community using community/school profiles or community census data.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served by the prevention education component of this intervention during this reporting period who considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted. If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data.

Ethnic Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Alternative Drug-Free Activities Sub-Form

65. When did you first start serving participants with this Alternative Drug-Free Activities component of the intervention, including all cycles? (Provide MM/YYYY.)

MM/YYYY ____________

Questions 66 through 74 pertain to alternative drug-free activities that were targeted at a specific group, such as high school students, college students, etc.

66. Are these recurring activities, in which the same group of people are served over multiple intervention sessions? (Select yes or no.)

 Yes

 No

67. Is the alternative drug-free activities component of this intervention 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 yes or no.)

 Yes

 No (If no, proceed to question 69.)

68. If the alternative drug-free activities component of this intervention is implemented in cycles, 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.)

69. How many new groups of participants started the alternative drug-free activities component of this intervention during this reporting period?

70. How many new groups of participants completed the alternative drug-free activities component of this intervention during this reporting period?

71. What was the total number of sessions provided for each group of participants in the alternative drug-free activities component of this intervention during this reporting period?

72. What was the average length of the individual sessions, in hours, during this reporting period?

hours

73. What was the format of the alternative drug-free activities component of this intervention during this reporting period? (Select all that apply.)

 Individual

 Small group (2-9)

 Large group (10-49)

 Extra large group (50+)

 Web-based

 Other (Describe.)

74. Indicate the types of participants served by the alternative drug-free activities component of this intervention during this reporting period. (Select all that apply.)

 Children age 0 to 3

 Children age 4 to 5

 Children age 6 to 11

 Youth age 12 to 17

 Young adults age 18 to 20

 Young adults age 21 to 24

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

75. As delivered, how would you classify the alternative drug-free activities component of this intervention according to the Institute of Medicine categories? (Select one response.)

 Universal

 Selective

 Indicated

Questions 76 through 78 pertain to alternative drug-free activities that were targeted at the general population, such as First Night Alcohol Free celebrations on New Year’s Eve.

76. 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 yes or no.)

 Yes

 No (If no, proceed to question 79.)

77. How many drug-free events were conducted during this reporting period?

78. How many people were reached through the drug-free events during this reporting period?

Use the table below to indicate the percentage of participants of each race served by the alternative drug-free activities component of this intervention during the reporting period.

If you do not know exact percentages of each race served, you may estimate percentages by determining the percentage of various races throughout the community using community/school profiles or community census data.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served by the alternative drug-free activities component of this intervention during this reporting period who considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted. If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data.

Ethnic Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Problem Identification and Referral Sub-Form

87. When did you first start serving participants with this Problem Identification and Referral component of the intervention, including all cycles? (Provide MM//YYYY.)

MM/YYYY ____________

88. Indicate the types of participants served by the Problem Identification and Referral component of this intervention during this reporting period. (Select all that apply.)

 Children age 0 to 3

 Children age 4 to 5

 Children age 6 to 11

 Youth age 12 to 17

 Young adults age 18 to 20

 Young adults age 21 to 24

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

89. What was the total number of individuals for whom problem identification and referral services were provided during this reporting period?

90. Where did problem identification and referral activities take place? (Select all that apply.)

 School

 Health care facilities

 Jails or prisons

 Courts

 Other (Describe.)

91. What type of services were individuals referred to? (Select all that apply.)

 Substance abuse treatment

 Mental health treatment

 Substance abuse prevention activities

 Housing services

 After school activities

 Transportation

 Day care or adult care services

 Other (Describe.)

Use the table below to indicate the percentage of participants of each race served by the problem identification and referral component of this intervention during the reporting period.

If you do not know exact percentages of each race served, you may estimate percentages by determining the percentage of various races throughout the community using community/school profiles or community census data.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served by the problem identification and referral component of this intervention during this reporting period that considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted. If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data.

Ethnic Category	a. Percentage of participants served	2. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Community-Based Processes Sub-Form

Indicate the activities that were conducted during this reporting period to enhance community resources (activities that will help the community address substance abuse and serve those with substance abuse problems), and provide activity details if asked.

100. Indicate the number of task force/coalition members you recruited during this reporting period, if any:

(If you did not do any work related to task forces or coalitions during this reporting period, proceed to question 103.)

101. Indicate the number of task force/coalition meetings you held during this reporting period, if any:

102. Indicate the number of task force/coalition members you trained during this reporting period, if any:

103. Indicate the number of other community members you trained during this reporting period, if any:

104. Did you coordinate funding with other organizations/projects during this reporting period? (Select yes or no.)

 Yes

 No

105. Did you develop interagency coordination mechanisms during this reporting period? (Select yes or no.)

 Yes

 No

106. Did you develop prevention or provider networks during this reporting period? (Select yes or no.)

 Yes

 No

107. 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.

108. Indicate the number of community organizations to whom you provided funding or other in-kind donations during this reporting period, if any:

(If none, proceed to question 110.)

109. How much funding did you provide to community organizations during this reporting period? (Include in-kind donations.)

110. Indicate the number of community organizations to whom you provided technical assistance during this reporting period, if any:

111. Did you reorganize local agencies to promote efficiency in delivering substance abuse prevention during this reporting period? (Select yes or no.)

 Yes

 No

112. Did you reallocate local funds for substance abuse prevention during this reporting period? (Select yes or no.)

 Yes

 No

113. Did you formally change 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 yes or no.)

 Yes

 No

114. Did you monitor regulatory or compliance changes by the state toward local or regional organizations during this reporting period? (Select yes or no.)

 Yes

 No

115. Did you conduct other community activities during this reporting period? (Select yes or no.)

 Yes (Describe.)

 No

116. How often did you conduct other community activities during this reporting period?

Use the table below to indicate the estimated percentages of each race that were targeted in the community-based processes component of this intervention during the reporting period.

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) row and the race row under African American.

Racial Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify.)	____%	1.
		2.
		3.

Use the table below to indicate the estimated percentage of Hispanic/Latino populations that were targeted in the community-based processes component of this intervention during this reporting period and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Environmental Strategies Sub-Form

Throughout this section, “you” refers to your organization, or partners with your organization. For example, if you worked with the police department to conduct more sobriety checkpoints, you would report this activity on this form. Indicate the type(s) of environmental strategies you worked to implement or implemented during this reporting period related to policy.

The questions below are an attempt to provide an exhaustive list of potential environmental strategies. SPF SIG community partners are not required to implement environmental strategies. The list below is meant to provide a standard way of reporting on environmental strategy implementation and activities. You will not be penalized if you indicate “no” as a response option. There is space at the end of this section to report on environmental strategies that are not listed here.

125. Did you work to enact open container laws prohibiting alcohol consumption in public places during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 127.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 127.)

126. Were you successful in your efforts to enact open container laws during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

127. Did you work to enact limits on the location, density , and hours of operation of liquor stores during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 129.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 129.)

128. Were you successful in your efforts to enact limits on the location, density , and hours of operation of liquor stores during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

129. Did you work to enact zoning ordinances to prohibit new alcohol outlets during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 131.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 131.)

130. Were you successful in your efforts to enact zoning ordinances during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

131. Did you work to enact limits on smoking in public places (e.g., movie theaters and restaurants) during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 133.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 133.)

132. Were you successful in your efforts to enact limits on smoking in public places during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

133. Did you work to enact limits on the use and placement of cigarette vending machines during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 135.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 135.)

134. Were you successful in your efforts to enact limits on the use and placement of cigarette vending machines during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

135. Did you work to enact regulations on alcohol or tobacco advertising and billboard placements in the community during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 137.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 137.)

136. Were you successful in your efforts to enact regulations on alcohol or tobacco advertising and billboard placements during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

137. Did you work to establish drug/alcohol/tobacco-free school zones and/or school use policies during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 139.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 139.)

138. Were you successful in your efforts to establish drug/alcohol/tobacco-free school zones and/or school use policies during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

139. Did you work to establish drug/alcohol/tobacco-free workplaces and/or workplace use policies during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 141.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 141.)

140. Were you successful in your efforts to establish drug/alcohol/tobacco-free workplaces and/or workplace use policies during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

141. Did you work to enact policies to reduce the problems/consequences associated with substance abuse (e.g., crime, driving under the influence, etc.) during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 143.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 143.)

142. Were you successful in your efforts to enact policies to reduce the problems/consequences associated with substance abuse during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

143. Did you work to implement organizational policies (e.g., within recreation leagues, summer camps, other non-governmental organizations) to reduce drug/alcohol/tobacco use among staff and youth during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 145.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 145.)

144. Were you successful in your efforts to implement organizational policies to reduce drug/alcohol/tobacco use among staff and youth during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

145. Did you work to implement keg registration during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 147.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 147.)

146. Were you successful in your efforts to implement keg registration during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

147. Did you conduct other policy interventions during this reporting period? (Select one response.)

 Yes (Describe.)________________________________________________

 No (If no, proceed to question 149.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 149.)

148. Were you successful in your efforts to conduct other policy interventions during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

Indicate which of the following activities you conducted during this reporting period, in order to affect policy change.

149. Did you contact your representatives (e.g., to prohibit alcohol consumption and smoking in public places) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 152.)

150. How many representatives were contacted during this reporting period?

151. How many issues did you contact your representatives about during this reporting period?

152. Did you provide information to elected officials about policies to be enacted (e.g., to prohibit new alcohol outlets in the community) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 155.)

153. How many elected officials were provided information during this reporting period?

154. How many policies did you provide information on during this reporting period?

155. Did you organize a ballot initiative during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 157.)

156. How many ballot initiatives were organized during this reporting period?

157. Did you work with school administrators and teachers to implement a drug-free policy during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 159.)

158. How many schools did you engage in policy implementation during this reporting period?

159. Did you work with businesses to implement a drug-free workplace during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 161.)

160. How many businesses did you engage in policy implementation during this reporting period?

161. Did you conduct other policy activities during this reporting period? (Select yes or no.)

 Yes (Describe.)___________________________________________________

 No (If no, proceed to question 163.)

162. How often did you conduct other policy activities during this reporting period?

Indicate the type(s) of environmental strategies you worked to implement or implemented during this reporting period related to enforcement.

163. Did you conduct compliance checks that target merchants who sell alcohol and tobacco to minors during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 166.)

164. How many compliance checks were conducted during this reporting period?

165. How many merchants were targeted during this reporting period?

166. Did you establish sobriety checkpoints during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 169.)

167. How many sobriety checkpoints were established during this reporting period?

168. Provide the frequency of checkpoints during this reporting period.

169. Did you set up surveillance of areas known for illegal drug sales during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 172.)

170. How many areas were targeted for surveillance during this reporting period?

171. Provide the frequency of the surveillance during this reporting period.

172. Did you work to increase building inspections during this reporting period from the number of inspections conducted prior to this reporting period? (Select yes or no.)

 Yes

 No

173. Did you work to ensure that policies to force landlords to improve or demolish run-down buildings were enforced during this reporting period? (Select yes or no.)

 Yes

 No

174. Did you make use of civil and criminal "nuisance abatement" statutes, which require landlords to evict tenants involved in narcotics-related activities or risk personal prosecution during this reporting period? (Select yes or no.)

 Yes

 No

175. Did you enforce policies to reduce the problems/consequences associated with substance abuse during this reporting period? (Select yes or no.)

 Yes

 No

176. Did you conduct other enforcement activities during this reporting period? (Select yes or no.)

 Yes (Describe.) ___________________________________________________

 No (If no, proceed to question 178.)

177. How often did you conduct other enforcement activities during this reporting period?

Indicate which of the following activities you conducted during this reporting period in order to implement environmental strategies related to enforcement: (Select all that apply.)

178. Did you educate law enforcement during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 181.)

179. How many law enforcement education sessions were conducted during this reporting period?

180. How many law enforcement officers were educated during this reporting period?

181. Did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community for sting operations, sobriety check-points, etc.) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 183.)

182. How many law enforcement officers were engaged in collaboration during this reporting period?

183. Did you conduct citizen patrols in neighborhoods known for illegal drug sales during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 187.)

184. How many citizen patrols were conducted during this reporting period?

185. How many neighborhoods known for illegal drug sales were patrolled during this reporting period?

186. Did you collaborate with municipal officials and private landlords to improve, rebuild, or raze abandoned buildings that are used to engage in drug use, adolescent alcohol use, and other illegal activities during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 189.)

187. How many municipal officials were engaged in collaboration during this reporting period?

188. How many private landlords were engaged in collaboration during this reporting period?

189. Did you conduct server training programs that work with bartenders and wait staff to reduce service to minors and intoxicated customers during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 192.)

190. How many server training programs were offered during this reporting period?

191. How many bartenders/wait staff were trained during this reporting period?

192. Did you educate merchants about the laws and penalties for selling to underage customers during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 195.)

193. How many merchant training programs were offered during this reporting period?

194. How many merchants were educated about the laws and penalties for selling to underage customers during this reporting period?

195. Did you conduct other enforcement activities during this reporting period? (Select yes or no.)

 Yes (Describe.)__________________________________________

 No (If no, proceed to question 197.)

196. How often did you conduct the other enforcement activities during this reporting period?

Indicate the type(s) of environmental strategies you implemented during this reporting period related to communication.

197. Did you engage in social marketing during this reporting period? Social Marketing is using 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. (Select yes or no.)

 Yes

 No (If no, proceed to question 208.)

198. How many social marketing campaigns were implemented during this reporting period?

199. How many television ads were created during this reporting period, as part of your social marketing campaigns?

200. How many television ads were aired during this reporting period, as part of your social marketing campaigns?

201. How many radio ads were created during this reporting period, as part of your social marketing campaigns?

202. How many radio ads were aired during this reporting period, as part of your social marketing campaigns?

203. How many print ads were created during this reporting period, as part of you social marketing campaigns?

204. How many print ads were published during this reporting period, as part of your social marketing campaigns?

205. How many special events (e.g., drug-free concert, smoke-free sponsored softball tournament) were hosted during this reporting period, as part of your social marketing campaigns?

206. How many other promotional activities (e.g., providing smoke-free pamphlets at a fair, distributing drug-free book covers at a school) were hosted during this reporting period as part of your social marketing campaigns?

207. How many promotional items were distributed during this reporting period, as part of your social marketing campaigns? Promotional items include pamphlets, brochures, leaflets, posters, videos or DVDs, and newsletters.

208. Did you engage in media literacy efforts during this reporting period? 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). (Select yes or no.)

 Yes

 No (If no, proceed to question 210.)

209. How many media literacy building sessions were held during this reporting period? A session is considered one class or gathering of participants. For example, if an intervention provides a class on tobacco ads and a class on alcohol ads, that would count as two sessions.

210. Did you conduct other communication interventions during this reporting period? (Select yes or no.)

 Yes (Describe.)_______________________________________________________

 No (If no, proceed to question 212.)

211. How often did you conduct other communication activities during this reporting period?

Indicate which of the following activities you conducted during this reporting period, in order to implement environmental strategies related to communication.

212. Did you present at community meetings (e.g., PTA meetings, town meetings, school assemblies) during this reporting period? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select yes or no.)

 Yes

 No (If no, proceed to question 215.)

213. How many community meetings were presented at during this reporting period?

214. What was the total number of participants at all community meetings where you presented during this reporting period?

215. Did you send letters to the editor of the local newspaper or community newsletters during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 218.)

216. How many letters were sent during this reporting period?

217. How many letters were published during this reporting period?

218. Did community members gather to show disapproval of upcoming alcohol-sponsored events during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 220.)

219. How many of the gatherings protesting alcohol-sponsored events were held during this reporting period?

220. Did you develop substance abuse prevention public service announcements (PSAs) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 222.)

221. How many PSAs were developed during this reporting period?

222. Did you broadcast substance abuse prevention public service announcements (PSAs) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 224.)

223. How often were the PSAs broadcast during this reporting period?

224. Did you produce and/or distribute substance abuse prevention posters?

 Yes

 No (If no, proceed to question 227.)

225. How many posters were distributed?

226. How many weeks are the posters scheduled to be displayed?

weeks

227. Did you develop prevention-focused Web site(s) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 229.)

228. How many hits did the Web site(s) receive during this reporting period?

229. Did you conduct other communication activities during this reporting period? (Select yes or no.)

 Yes (Describe.)____________________________________________________

 No (If no, proceed to question 231.)

230. How often did you conduct other communication activities during this reporting period?

231. Describe any other type(s) of environmental strategies you worked to implement or implemented during this reporting period that do not fall into the categories listed above.

(Provide a concise written description in the space available.)

232. What individuals or organizations did you work with in planning or implementing environmental strategies during this reporting period? (Select all that apply.)

 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.)_____________________________________________________

233. When did you first start conducting environmental strategies as part of this intervention? (Provide MM/YYYY.)

MM/YYYY ____________

Use the table below to indicate the estimated percentages of each race that you targeted with the environmental strategies component of this intervention during the reporting period.

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) row and the race row under African American.

Racial Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify.)	____%	1.
		2.
		3.

Use the table below to indicate the estimated percentage of Hispanic/Latino populations you targeted with the environmental strategies component of this intervention during the reporting period and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Information Dissemination Sub-Form

For this section, do not include activities or information that you have reported in other areas, such as the environmental strategies section.

242. What types of information did you disseminate? (Select all that apply.)

 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.)________________________________________

243. What format was the information you disseminated? (Select all that apply.)

 Brochures

 Flyers

 Magnets

 Other promotional items (Frisbees, balls, cups)

 Other (Describe.)________________________________________

244. 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.

___________________

245. Approximately how many individuals received the information disseminated?

___________________

246. What individuals or organizations did you work with in planning or implementing your information dissemination efforts during this reporting period? (Select all that apply.)

 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.)_____________________________________________________

247. When did you first start conducting information dissemination activities as part of this intervention? (Provide MM/YYYY.)

MM/YYYY _____________

Use the table below to indicate the estimated percentages of each race that you targeted with the information dissemination activities component of this intervention during the reporting period.

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) row and the race row under African American.

Racial Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify.)	____%	1.
		2.
		3.

Use the table below to indicate the estimated percentage of Hispanic/Latino populations you targeted with the information dissemination activities component of this intervention and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Other Activities or Services Delivered to Individuals Sub-Form

If your intervention included components delivered to individuals other than prevention education, alternative drug-free activities or problem identification and referral, use this form to provide information about this component.

256. Describe any other component of the intervention that was delivered to individuals.

257. When did you first start conducting this component of the intervention? (Provide MM/YYYY.)

MM/YYYY

258. What was the average duration of one session during this reporting period?

hours

259. How many sessions did you conduct during this reporting period?

260. What was the format of this component during this reporting period? (Select all that apply.)

 Individual

 Small group (2-9)

 Large group (10-49)

 Extra large group (50+)

 Web-based

 Other (Describe.)

261. Indicate the types of participants served by this component during this reporting period. (Select all that apply.)

 Children age 0 to 3

 Children age 4 to 5

 Children age 6 to 11

 Youth age 12 to 17

 Young adults age 18 to 20

 Young adults age 21 to 24

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

262. As delivered, how would you classify this other intervention component according to the Institute of Medicine categories? (Select one response.)

 Universal

 Selective

 Indicated

Use the table below to indicate the percentage (or to estimate the percentage) of participants served by your other component of each race during the reporting period.

If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served during this reporting period that considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Other Activities or Services Not Delivered to Individuals Sub-Form

If you used a component other than community-based processes, environmental strategies, or information dissemination to implement your intervention that did not involve specific participants, use this form to provide information about this component

271. Describe the activities or services you provided that were not delivered to individuals. Make sure to include reports of any counts or frequencies, as they apply.

272. Describe the intended target population for these activities or services.

273. When did you first start conducting these other non-participant based activities, as a component of this intervention? (Provide MM/YYYY.)

MM/YYYY

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