SA_Reporting _Sect SA_Reporting _Section

www.samhsa.gov • 1-877-SAMHSA-7 (1-877-726-4727)

Behavioral Health is Essential To Health • Prevention Works • Treatment is Effective • People Recover

FY 2012
Block Grant Reporting Section
CFDA 93.959 (Substance Abuse Prevention and Treatment)

R e d u c i n g t h e i m p a c t o f s u b s t a n c e a b u s e a n d m e n t a l i l l n e s s o n A m e r i c a ’s c o m m u n i t i e s .

·

Table of Contents

A.
B.
C.
D.
E.

Introduction
Annual Report
State Agency Expenditure Report
Population and Services Report
Performance Indicators and Accomplishments

A. Introduction
Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. 300x-52(a)) requires
the Secretary of the Department of Health and Human Services, acting through the Administrator
of the Substance Abuse and Mental Health Services Administration (SAMHSA), to determine
the extent to which States and Jurisdictions have implemented the State plan for the prior fiscal
year. The purpose of the Annual Report is to provide information to assist the Secretary in
making this determination.
States and Jurisdictions are requested to prepare and submit their reports for the last completed
fiscal year in the format provided in this guidance. The report will address the purposes for
which the SABG funds were expended, the recipients of grant funds, and the authorized
activities and services purchased with such funds. Particular attention should be given to the
progress made toward accomplishing the goals and performance indicators identified in the
States’ and Jurisdictions’ plans.
All States and Jurisdictions are required to prepare and submit their respective reports utilizing
SAMHSA’s Web Block Grant Application System (BGAS). The report must be received by
SAMHSA not later than December 1 in order for State or Jurisdiction to receive a grant for the
subsequent Federal fiscal year. If the due date falls on a weekend or Federal holiday, the report
will be due on the next business day. The following schedule provides specific due dates for
annual reports:
Table 1

2013

Plan and Repor t Receipt Dates
Plan Receipt
Planning Per iod
Repor t Receipt
Date
Date
9/01/2011
10/01/2011 –
12/01/2011
06/30/2013
12/01/2012

2014

04/01/2013

Application for Feder al fiscal
year
2012

07/01/2013 06/30/2015

2015
2016
2017

12/01/2013
12/01/2014

04/01/2015

07/01/2015 –
06/30/2017

12/01/2015
12/01/2016

Repor t Per iod
10/01/2010 09/30/2011
07/01/2011 06/30/2012
07/01/2012 –
06/30/2013
07/01/2013 –
06/30/2014
07/01/2014 –
06/30/2015
07/01/2015 06/30/2016

States/Territories are required to prepare and submit a report comprised of the following
sections:
Section B: Annual Report - In this first section, States and Jurisdictions are required to provide a
brief review of the extent to which their respective plans were implemented, the progress
towards the priorities and goals identified in the Block Grant application. The report should also
include a brief review of areas that the State and Jurisdiction identified in Block Grant
Application as needing improvement and changes that the State and Jurisdiction would propose
to achieve the goals established for the priorities.

Section C: State Agency Expenditure Report - In this section, States should provide information
regarding expenditures for authorized activities and services for mental health, substance abuse
prevention, and substance abuse treatment. States should provide a description of SAPTBG
expenditures for authorized activities to prevent and treat substance abuse and related services
for tuberculosis and other communicable diseases and if a “designated State,” a description of
SAPTBG expenditures for early intervention services for HIV. In addition, States should
identify the SAPTBG expenditures made available to intermediaries, administrative service
organizations, and community- and faith-based organization who received amounts from the
SAPTBG to provide authorized activities to prevent and treat substance abuse
Section D: Populations and Services Report - In this section, States and Jurisdictions must
provide specific information regarding the number of individuals that were served with SAPTBG
funds. In addition, States and Jurisdictions should provide specific information regarding the
services these individuals received.
Section E: Performance Indicators and Accomplishments - In this section of the report, States
and Jurisdictions are required to complete the Performance Indicator tables. Performance
indicators should be reported using the table format provided in this document. The purpose of
the performance indicator tables is to show progress made over time as measured by SAMHSA’s
National Outcome Measures (NOMS) for substance abuse prevention, treatment, and recovery
support services as well as any State- or Jurisdiction-selected performance indicators.

B. Implementation Report
As part of the planning section, States identified their priorities in addition to the joint planning
areas and the statutorily required priorities. This table should be filled out for all priority areas
that the State will focus on during the planning period. The same table will be used to capture
progress reporting.
At the end of each priority area, the State should clearly indicate whether or not the particular
goal identified in the State Plan for the prior fiscal year was “achieved” or “not achieved.” If a
target was “not achieved,” explain why.

Table 2
Report Year(s):
State Identifier:
State Priorities
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Add more priority areas as needed

Table 3, Priority Area by Goal, Strategy, and Performance Indicator, should be completed for
each priority areas identified by States and Jurisdictions in their respective State plans and for
which fiscal resources were expended during the prior State fiscal year.
At the end of each priority area, States and Jurisdictions should clearly indicate whether or not
the particular goal identified in the State plan for the prior State fiscal year was “achieved” or
“not achieved.” If a target was “not achieved,” a detailed explanation must be provided.
Table 3
Report Year(s):
State Identifier:
Priority Area:
Goal:
Strategy: (use as many lines as needed for each strategy)
Performance Indicator:
Description of Collecting and Measuring Changes in Performance Indicator:

Report of Progress toward goal attainment in prior State Fiscal Year:
____ Achieved

_____ Not Achieved (if not achieved, explain why)

Changes Proposed to Meet Goal

C. Expenditure Reports
Substance Abuse Treatment and Prevention Block Grant Spending
States and Jurisdictions are requested to provide information regarding SAPT Block Grant and
State general revenue funds expended for authorized activities to prevent and treat substance
abuse and for related public health services, e.g., tuberculosis services and early intervention
services for HIV, if applicable, during the prior State fiscal year. Please complete the tables
described below:
•

•
•
•
•

•

•

•

•

Table 4 - State Agency Expenditure Report. This table provides a description of
SAPTBG expenditures for authorized activities to prevent and treat substance abuse
pursuant to section 1921 of Title XIX, Part B, Subpart II of the Public Health Service
(PHS) Act (42 U.S.C. 300x-21), tuberculosis services and early intervention services, if
applicable, pursuant to section 1924 of Title XIX, Part B, Subpart II of the PHS Act (42
U.S.C. 300x-24) and administration pursuant to section 1931 of Title XIX, Part B,
Subpart II of the PHS Act (42 U.S.C. 300x-31(a)(1)(F)).
Table 5 - SAPT Block Grant Expenditures By Service. This table provides a description
of SAPT Block Grant expenditures by unduplicated individual and specific services.
Table 6- Primary Prevention Expenditures Checklist. This table provides a description of
SAPT Block Grant expenditures on primary prevention strategies funded by State
Substance Abuse Authority.
Table 7 - Resource Development Expenditure Checklist. This table provides a
description of the SAPT Block Grant expenditures for non-direct activities and/or
services that are sponsored, or conducted by the State Substance Abuse Authority.
Table 8 – Statewide Entity Inventory. This table provides a description of the recipients
of SAPT Block Grant funds including intermediaries, e.g., administrative service
organizations, and community- and faith-based organizations which provided substance
abuse prevention activities and treatment services during the prior State fiscal year. The
table has been amended to include recipients of MHBG Block Grant funds for those
states submitting one application.
Table 9a - Maintenance of Effort for State Expenditures for Substance Abuse Prevention
and Treatment. This table provides a description of non-Federal expenditures for
authorized activities to prevent and treat substance abuse flowing through the State
Substance Abuse Authority during each fiscal year.
Table 9b - Base and Maintenance of Effort for State Expenditures for Tuberculosis
Services. This table provides a description of non-Federal funds expended for
tuberculosis (TB) services made available to individuals in substance user disorder
(SUD) treatment during each fiscal year (FY).
Table 9c - Base and Maintenance of Effort for State Expenditures for Early Intervention
Services for HIV Disease. This table provides a description of non-Federal funds
expended for early intervention services for HIV disease provided to individuals in
substance use disorder treatment at the sites at which such individuals received SUD
treatment services during each fiscal year (FY).
Table 9d - Base and Maintenance of Effort for Expenditures for Services Designed for
Substance Using Pregnant Women and Women with Dependent Children. This table
provides a description of SAPT Block Grant and State general revenue expenditures for

services designed to address the treatment and recovery support needs of substance using
pregnant women and women with dependent children during each fiscal year (FY).

Table 4 - State Agency Expenditure Report. This table provides a description of SAPT Block Grant expenditures for authorized activities to
prevent and treat substance abuse. Note: This table may also be used to describe CMHS Block Grant expenditures for authorized activities
regarding mental health services for seriously emotionally disturbed (SED) adolescents and seriously mentally ill (SMI) adults.
Table 4
Report Year:
State Identifier:
State Agency Expenditure Report
(Include ONLY funds expended by the executive branch agency administering the SAPT Block Grants and the CMHS Block Grant*)
Source of Funds
ACTIVITY
(See instr uctions for using Row 1.)

1.

Substance Abuse Pr evention**
and Tr eatment

2.

Pr imar y Pr evention

3.

Tuber culosis Ser vices

4.

HIV Ear ly Inter vention
Ser vices

5.

State Hospital

A.
Substance Abuse
Block Gr ant

B.
Mental Health
Block Gr ant.
Block Gr ant

C. Medicaid
(Feder al, State,
and local)

D. Other Feder al
Funds (e.g., ACF
(TANF), CDC,
CMS (Medicar e)
SAMHSA, etc.)

E. State funds

F. Local funds
(excluding local
Medicaid)

G. Other

6. Other 24 Hour Car e
7. Ambulator y/Community Non-24
Hour Car e
8. Administr ation (excluding
pr ogr am / pr ovider level
9. Subtotal (Rows 1, 2 3, 4, and 8)
10. Subtotal (Rows 5, 6, 7, and 8)
11. Total
* States and Jurisdictions may utilize a single table to report expenditures for the SAPT and CMHS Block Grants if a State or Jurisdiction submits a single report to
SAMHSA**Prevention other than Primary Prevention

Table 5: SAPTBG Expenditures by Service
Table 5
Report Year:
State Identifier:
Service
Healthcare Home/Physical Health
General and specialized outpatient medical services
Acute Primary care
General Health Screens, Tests and Immunizations
Comprehensive Care Management
Care coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community Services
Prevention (Including Promotion)
Screening, Brief Intervention and Referral to Treatment
Brief Motivational Interviews
Screening and Brief Intervention for Tobacco Cessation
Parent Training
Facilitated Referrals
Relapse Prevention/Wellness Recovery Support
Warm Line
Engagement Services
Assessment
Specialized Evaluations (Psychological and Neurological)
Service Planning (including crisis planning)
Consumer/Family Education
Outreach
Outpatient Services
Individual evidenced based therapies
Group therapy
Family therapy
Multi-family therapy
Consultation to Caregivers

SAPT Block Grant Expenditures by Service
Unduplicated Individuals

Units

Expenditures

Table 5
Report Year:
State Identifier:
Service
Medication Services
Medication management
Pharmacotherapy (including MAT)
Laboratory services
Community Support (Rehabilitative)
Parent/Caregiver Support
Skill building (social, daily living, cognitive)
Case management
Behavior management
Supported employment
Permanent supported housing
Recovery housing
Therapeutic mentoring
Traditional healing services
Recovery Supports
Peer Support
Recovery Support Coaching
Recovery Support Center Services
Supports for Self Directed Care
Other Supports (Habilitative)
Personal care
Homemaker
Respite
Supported Education
Transportation
Assisted living services
Recreational services
Trained behavioral health interpreters
Interactive communication technology devices
Intensive Support Services
Substance abuse intensive outpatient (IOP)
Partial hospital

SAPT Block Grant Expenditures by Service
Unduplicated Individuals

Units

Expenditures

Table 5
Report Year:
State Identifier:
Service
Assertive Community Treatment
Intensive home based services
Multi-systemic therapy
Intensive Case Management
Out of Home Residential Services
Crisis residential/stabilization
Clinically Managed 24 Hour Care (SA)
Clinically Managed Medium Intensity Care (SA)
Adult Substance Abuse Residential
Adult Mental Health Residential
Youth Substance Abuse Residential Services
Children's Residential Mental Health Services
Therapeutic foster care
Acute Intensive Services
Mobile crisis
Peer based crisis services
Urgent care
23 hr. observation bed
Medically Monitored Intensive Inpatient (SA)
24/7 crisis hotline services
Other (please list)

SAPT Block Grant Expenditures by Service
Unduplicated Individuals

Units

Expenditures

Primary Prevention Expenditures Checklists
Table 6 (a and b): Detailing expenditures on primary prevention.
There are six primary prevention strategies typically funded by principal agencies administering
the SAPT Block Grant. Expenditures within each of the six strategies or Institute of Medicine
(IOM) Model should be directly associated with the cost of completing the activity or task, for
example information dissemination should include the cost of developing pamphlets, the time of
participating staff or the cost of public service announcements etc. If a State employs strategies
not covered by these six categories, please report them under “Other” in a separate row for each
one in Form 3.
Section 1926 – Tobacco: Costs Associated with the Synar Program. Per January 19, 1996, 45
C.F.R. Part 96, Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants;
Final Rule (45 C.F.R. §96.130), States may not use the Block Grant to fund the enforcement of
their statute, except that they may expend funds from their primary prevention set aside of their
Block Grant allotment under 45 C.F.R. §96.124(b)(1) for carrying out the administrative aspects
of the requirements such as the development of the sample design and the conducting of the
inspections.
States should include any non-SAPT Block Grant funds that were allotted for Synar activities in
the appropriate columns.
Refer back to Form 1 and look at all the entries you made on row 2 primary prevention. Use the
table below to indicate how much funding supported each of the six strategies on Form 1a or how
much funding supported each of the IOM classifications, Universal, Selective or Indicated on
Form 1b. Enter in whole dollar amounts. For sources of funds other than the SAPT Block Grant,
report only those funds made available during the 24 month expenditure period identified on
Form 1
.

Table 6: Primary Prevention Expenditures Checklist
Table 6
Report Year:
State Identifier:
Strategy

A.
IOM Target

Primary Prevention Expenditures Checklist
B.
C.
SAPT Block Grant
Other Federal

D.
State

E.
Local

F. Other

1. Infor mation Dissemination

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

Unspecified

$

$

$

$

$

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

Unspecified

$

$

$

$

$

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

Unspecified

$

$

$

$

$

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

Unspecified

$

$

$

$

$

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

2. Education

3. Alter natives

4. Pr oblem Identification and Refer r al

5. Community-Based Pr ocesses

6. Envir onmental

7. Section 1926-Tobacco

8. Other

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

Unspecified

$

$

$

$

$

Universal

$

$

$

$

$

Selected

$

$

$

$

$

Indicated

$

$

$

$

$

Universal

$

$

$

$

$

Selected

$

$

$

$

$

$

$

$

$
$
Indicated
*Please lit all sources, if possible (e.g.., Centers for Disease Control and Prevention, Block Grant, foundations, etc.)

Table 7: Resource Development Expenditures Checklist
Only complete this table if your State or Jurisdiction funds resource development activities from the FY 2011 SAPT Block Grant
Table 7
Report Year:
State Identifier:
Activity

Resource Development Expenditures Checklist
A. Prevention-MH
B. Prevention-SA
C. Treatment-MH

D. Treatment-SA

E. Combined

F. Total

1. Planning, coor dination, and needs assessment

$

$

$

$

$

$

2. Quality Assur ance

$

$

$

$

$

$

3. Tr aining (post-employment)

$

$

$

$

$

$

4. Education (pr e-employment)

$

$

$

$

$

$

5. Pr ogr am development

$

$

$

$

$

$

6. Resear ch and evaluation

$

$

$

$

$

$

7. Infor mation Systems

$

$

$

$

$

$

8. Total

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

Table 8. Statewide Entity Inventory
Table 8
Report Year:
State Identifier:
Entity Inventory

Entity
Number

Total

ISATS
ID
(For
SABG)

Area
Served
(Statewide
or SubState
Planning
Area)

Provider/Program
Name

Street
Address

City

State

Zip

A
Block
Grant
Funds

$
$
$

B
Prevention
(other than
primary
prevention)
and
Treatment
Services
$
$
$

Source of Funds
SAPT Block Grant
B
D
E
Pregnant
Primary
Early
Women
Prevention Intervention
and
Services for
Women
HIV
with
Dependent
Children
$
$
$
$
$
$
$
$
$

CMHS Block Grant
F
G
Adults Children
serious with a
mental serious
illness
emotional
disturbance

$
$
$

$
$
$

Table 9a, 9b, 9c, and 9d Maintenance of Effort for State Expenditures for Authorized
Activities to Prevent and Treat Substance Abuse and Related Public Health Services
Table 9a, Total Single State Agency Expenditures for Substance Abuse Prevention and
Treatment, provides a description of non-Federal expenditures for authorized activities to prevent
and treat substance abuse flowing through the State Substance Abuse Authority (SSA) during
each State fiscal year (SFY).
Did the State or Jurisdiction have any non-recurring expenditures for a specific purpose which
were not included in the MOE calculation?
Yes____

No ___

If yes, specify the amount and the State fiscal year ___________.
Did the State or Jurisdiction include these funds in previous year MOE calculations? Yes___
No___.
When did the State or Jurisdiction submit an official request to the SAMHSA Administrator to
exclude these funds from the MOE calculations?
mm/dd/yyyy

Table 9a. Maintenance of Effort for State Expenditures for Substance Abuse Prevention and
Treatment
Table 9a
Report Year:
State Identifier:
Total Single State Agency (SSA) Expenditur es for Substance Abuse Pr evention and Tr eatment
Period

Expenditures

B1 (2009) + B2 (2010)
2

(A)

(B)

(C)

SFY 2009
(1)
SFY 2010
(2)
SFY 2011
(3)

Are the expenditure amounts reported in Columns B “actual” expenditures for the State fiscal years involved?
FY 2009
FY 2010
FY 2011

Yes
Yes
Yes

No
No
No

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

Table 9b and 9c, Base and Maintenance of Effort for State Expenditures for Tuberculosis to Individuals in Substance Use Disorder
Treatment, provides a description of all statewide, non-Federal funds expended on Tuberculosis (TB) services to individuals in substance use
disorder treatment during each State fiscal year (SFY).
Table 9b
Repor t Year
State Identifier :
Statewide Non-Feder al Expenditur es for Tuber culosis Ser vices to Individuals in Substance Use Disor der Tr eatment
BASE
Period

Total of All State
Funds Spent on TB
Services

% of TB Expenditures Spent on
Individuals in Substance Use
Disorder Treatment

(A)

(B)

Total State Funds Spent on
Individuals in Substance Use
Disorders Treatment (AxB)
(C)

Average of
Column C1 and C2
C1 + C2
2
(MOE BASE)
(D)

SFY 1991
(1)
SFY 1992
(2)

OMB No. 0930-0080

Table 9b
Repor t Year
State Identifier :
Statewide Non-Feder al Expenditur es for Tuber culosis Ser vices to Individuals in Substance Use Disor der Tr eatment
MAINTENANCE

Period

Total of All State
Funds Spent on TB
Services

% of TB Expenditures Spent on
Individuals in Substance Use
Disorder Treatment

(A)

(B)

Total State Funds Spent on
Individuals in Substance Use
Disorders Treatment (AxB)
(C)

Average of
Column C1 and C2
C1 + C2
2
(MOE BASE)
(D)

SFY 2011
(2)

OMB No. 0930-0080

Table 9c, State Expenditures for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment, Base and
Maintenance.
Enter the year in which your State last became a designated State, Federal Fiscal Year____. Enter the 2 prior years’ expenditure data in A1
and A2. Compute the average of the amounts in boxes A1 and A2. Enter the resulting average (MOE Base) in box B2.
Table 9c
Repor t Year :
State Identifier :
Statewide Non-Feder al Expenditur es for HIV Ear ly Inter vention Ser vices to Individuals in Substance Use Disor der Tr eatment
BASE
Period

Total of All State Funds Spent on Early Intervention
Services for HIV

(A)
(1) SFY ____

(2)

SFY____

Average of Columns
A1 and A2
A1+A2
2
(MOE Base)
(B)

OMB No. 0930-0080

Table 9c
Report Year
State Identifier
Statewide Non-Federal Expenditures for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment
MAINTENANCE
Period

(3)

SFY 2011

Total of All State Funds Spent on Early Intervention Services for HIV
(A)

OMB No. 0930-0080

Table 9d. Expenditures for Services to Pregnant Women and Women with Dependent Children, Base and Maintenance.

Table 9d
Repor t Year :
State Identifier :
Expenditur es for Ser vices to Pr egnant Women and Women with Dependent Childr en
Per iod

Total Women’s Base

Total Expenditur es

(A)

(B)

1994
2009
2010
2011
Enter the amount the State plans to expend in 2012 for services for pregnant women and women with dependent children (amount entered must be not less than amount
entered in Table 9d Maintenance - Box A (1994)): $ __________

D. Populations and Services Report
States and Jurisdictions are required to provide information regarding individuals that are served
by the State Substance Abuse Authority using Tables 10 through 16 as described below.
•

•

•

•

•

•

Table 10 - Prevention Strategy Report. This table requires additional information (in
accordance with Section 1929 of Title XIX, Part B, Subpart II of the PHS Act) about the
primary prevention activities conducted by the entities listed on Table 8, Entity Inventory,
Column D. It seeks further information on the specific strategies and activities being
funded by the principal agency of the State that addresses the sub-populations at risk for
alcohol, tobacco, and other drug (ATOD) use/abuse.
Table 11 - Treatment Utilization Matrix. This table is intended to capture the
unduplicated count of persons with initial admissions and subsequent admission to an
episode of care (as defined in the Drug and Alcohol Services Information System
Treatment Episode Data Set (TEDS) http://oas.samhsa.gov/dasis.htm#teds2 standards).
Table 12 - Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug
Use. This table provides an aggregate profile of unduplicated number of admissions and
persons in FY 2011 for services funded through the SABG. States and Jurisdictions are
to provide this information on all programs by age, gender, and race/ethnicity. States and
Jurisdictions are to report whether the values reported come from a client-based system(s)
with unique client identifiers.
Tables 13a – e - Demonstration Syringe Services Program. The tables are intended to
capture information about State Syringe Service Programs. States and Jurisdictions are to
provide this information on all Syringe Service Programs and demographics of
participants.
Table 14 - HIV Designated States Early Intervention Services. This table requires
“Designated States”, as defined in section 1924(b) of Title XIX, Part B. Subpart II of the
PHS Act (42 U.S.C. 300x-24(b)), to provide information on Early Intervention Services
for HIV testing and referral.
Table 15 - Charitable Choice. This table requires States and Jurisdictions to provide
information regarding compliance with section 1955 of Title XIX, Part B, Subpart III of
the PHS Act (42 U.S.C. 300x-65) and the Charitable Choice Provisions and Regulations;
Final Rule (42 C.F.R. Part 54)

Table 10. Prevention Strategy Report
Table 10
Report Year
State Identifier
Prevention Strategy Report Risk-Strategies
Column A (Risks)

Childr en of Substance Abuser s [1]
Pregnant Women / Teens [2]
Drop-Outs [3]
Violent and Delinquent Behavior [4]
Mental Health Problems [5]
Economically Disadvantaged [6]
Physically Disabled [7]
Abuse Victims [8]
Already Using Substances [9]
Homeless and/or Runaway Youth [10]
Other, Specify [11]

Column B (Strategies)

Column C (Providers)

Table 11. Treatment Utilization Matrix
Table 11
Report Year
State Identifier
Treatment Utilization Matrix

Level Of Care

Number of Admissions ≥ Number of Persons Served
Number
Number of
of Admissions
Persons Served
(A)
(B)

Costs per Person
Mean Cost of Services
(C)

Median Cost of Services
(D)

Standard Deviation of Cost
(E)

Detoxification (24-Hour Car e)
1. Hospital Inpatient

$

$

$

2. Free-Standing
Residential

$

$

$

3. Hospital Inpatient

$

$

$

4. Short-term (up to 30
days)

$

$

$

5. Long-term (over 30
days)

$

$

$

6. Outpatient

$

$

$

7. Intensive Outpatient

$

$

$

8. Detoxification

$

$

$

Rehabilitation/Residential

Ambulatory (Outpatient)

9. Upload Replacement
Therapy

$

$

$

Table 12. Unduplicated Count of Persons Served for Alcohol and Other Drug Use
Table 12
Report Year:
State Identifier:

Age

A. Total

1. 17 and
under
2. 18-24
3.

25-44

4.

45-64

5. 65 and
over
5. Total
7. Pregnant
Women
Numbers of Persons Served
who were admitted in a
Period Prior to the 12
month reporting Period
Number of persons served
outside of the levels of care
described on Table 11

Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State Funded Services by Age, Sex and Race/Ethnicity
Sex and Race/Ethnicity
B. White
C. Black or
D. Native
E. Asian
F. American
G. More Than
H. Unknown
I. Not Hispanic
African
Hawaiian/
Indian/Alaskan
One Race
or Latino
American
Other Pacific
Native
Reported
Islander
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F

J. Hispanic
or Latino

M

F

Demonstration Syringe Services Program
Table 13a Syringe Services Program

State Fiscal Year:________

State Syringe Services Programs
List all State and/or local agencies participating/collaborating in demonstration
Syringe Services Programs (SSPs):
Number of SSPs supported with SAPT funds:
List all services offered (e.g., testing, counseling, referral, transportation):
Number and types of educational and communication materials provided:
Number of new/sterile syringes provided:
Number of used/contaminated syringes collected:
If applicable, list all adverse or potentially disruptive incidents (e.g., community
opposition, law enforcement encounters, needle stick injuries, etc.):

Table 13b SSPs─Demographics of Participants

AGE

A.
Total

B. White

M
1. 17&Under
2. 18-24
3. 25-44
4. 45-64
5. 65 and Over
6. Total
Pregnant
women

C. Black or
African
American
F

M

F

D. Native
Hawaiian/Other
Pacific Islander
M

F

E. Asian

M

F. American
Indian/Alaska
Native
F

M

F

G. More
Than One
Race
Reported
M
F

H.
Unknown

M

F

I. Not
Hispanic or
Latino
M

F

J. Hispanic
or Latino

M

F

Table 13c SSP ─Tallies by Programs (SUD Treatment)
SSP
Number of Number of
Frequency of injection
Program
Exchange
drug use reported by
Participants Syringes
program participants
Same

Less

Number of
referrals to
SUD
Treatmetn

Number of
Admissions to
SUD Treatment

Number of
participants who
ompleted
SUDTreatment

More

SSP1:
SSP2:
Total:
Table 13d SSP ─Tallies by Programs (HIV and HCV Services)
SSP
Number of Number of .
Number of
Number of
Participants referrals to
completed
participants
HIV
HIV
who .
counseling
counseling
received
and testing
sessions
HIV testing
SSP1:
SSP2:
Total:

Number of
participants
who .
received
other HIV
health care

Average
number of .
HIV health
care visits by
SSP
participant

Number of .
referrals to
HCV
counseling
and testing

Number of
completed
HCV
counseling
session

Number of
participants
who.
received
HCV testing

Table 13e SSP ─Tallies by Programs (Mental Health and Supportive Services)
SSP
Number of
Number of
Number of
Number of
Number of
.participants referrals to
participants.
participants
referrals to
MH
admitted to M who
supportive
treatment
H treatment
completed
services
MH
treatment
SSP1:
SSP2:
Total:

Number of
participants
who received
supportive
services

Table 14. HIV Designated States Early Intervention Services
Table 14
Report Year:
State Identifier
Early Intervention Services for Human Immunodeficiency Virus (HIV)
1. Number of SAPT HIV EIS programs funded in the State:
Statewide:_____
Rural:_____
2. Total number of individuals tested through SAPT HIV EIS
funded programs:
3. Total number of HIV tests conducted with SAPT HIV EIS
funds:
4. Total number of tests that were positive for HIV:
5. Total number of individuals who prior to the 12-month
reporting period were unaware of their HIV infection:
6. Total number of HIV-infected individuals who were diagnosed
and referred into treatment and care during the 12-month reporting
period
Identify barriers, including State laws and regulations, that exist in carrying out HIV testing services:

Table 15. Charitable Choice
Under Charitable Choice, States, local governments, and religious organizations, each as
SAMHSA grant recipients, must: (1) ensure that religious organizations that are providers
provide notice of their right to alternative services to all potential and actual program
beneficiaries (services recipients); (2) ensure that religious organizations that are providers refer
program beneficiaries to alternative services; and (3) fund and/or provide alternative services.
The term “alternative services” means services determined by the State to be accessible and
comparable and provided within a reasonable period of time from another substance abuse
provider (“alternative provider”) to which the program beneficiary (“services recipient”) has no
religious objection. The purpose of this table is to document how your State is complying with
these provisions.
Notice to Program Beneficiaries – Check all that apply:
□ Used model notice provided in final regulations.
□ Used notice developed by State (please attach a copy to the Report)
□ State has disseminated notice to religious organizations that are providers.
□ State requires these religious organizations to give notice to all potential beneficiaries.
Referrals to Alternative Services – Check all that apply:


State has developed specific referral system for this requirement.



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



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



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



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



Enter total number of referrals necessitated by religious objection to other
substance abuse providers (“alternative providers”), as defined above, made in
previous fiscal year. Provide total only; no information on specific referrals
required.

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

E.

Performance Data and Outcomes

SAMHSA is interested in demonstrating program accountability and efficacy through the
National Outcome Measures (NOMs). The NOMs are intended to document the performance of
federally supported programs and systems of care.
Treatment Performance Measures
• Table 16. - Employment/Education Status. This table describes the status of adult clients
served in the report year by the public substance abuse system in terms of employment
and education status. The Employment\Education Status Form seeks information on
clients employed or student (full-time or part-time) (prior 30 days) at admission vs.
discharge.
• Table 17 - Stability of Housing. This table requests information regarding the number of
Individuals in a Stable Living Environment as collected by the most recent assessment in
the reporting period. Specifically, information is collected on the individual’s last known
living situation.
• Table 18 - Criminal Justice Involvement. This table requests information regarding the
client’s involvement in the criminal justice system. Specifically, the table requests
information to measure the change in Arrests over time.
• Table 19 – Change in Abstinence–Alcohol Use. This table seeks information regarding
alcohol abstinence. Specifically, information is collected on the number of clients with
no alcohol use (all clients regardless of primary problem) at admission and discharge.
• Table 20 - Change in Abstinence – Other Drug Use. This table collects information
regarding clients change in abstinence with other drugs. This table seeks to collect
information on clients with no drug use (all clients regardless of primary problem) at
admission and discharge
• Table 21 – Change in Social Support of Recovery. This table seeks to measure the
change in client’s social support or recovery. Specifically, this form collects information
regarding the number of clients participating in self help groups at admission and
discharge
• Table 22 - Retention. This table collects information regarding retention. Specifically,
this table collects information regarding the length of stay of clients completing
treatment.
Prevention Performance Measures
• Table 23. Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: 30 Day
Use. This table collects information on abstinence from drug use/alcohol use. This table
collects information on the percent who reported having used alcohol during the past 30
days.
•

Table 24. Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure:
Perception Of Risk/Harm of Use. This table seeks information regarding the individuals’
perceived risk of harming themselves with alcohol, tobacco and other drugs.

•

Table 25. Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Age of
First Use. This table seeks information regarding the age of first use of alcohol, cigarettes
and other drugs.

•
•
•
•
•
•

•
•

•

•

•
•

Table 26. Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure:
Perception of Disapproval/Attitudes. This table seeks information regarding the general
public perception or attitude regarding use of alcohol, cigarettes and other drugs.
Table 27. Employment/Education; Measure: Perception of Workplace Policy. This table
reports the percent of individuals who would be more likely to work for an employer
conducting random drug and alcohol tests.
Table 28. Employment/Education; Measure: Average Daily School Attendance Rate. This
table collects information regarding the average daily school attendance.
Table 29. Crime and Criminal Justice; Measure: Alcohol-Related Traffic Fatalities. This
table collects information regarding the number of alcohol-related traffic fatalities
divided by the total number of traffic fatalities and multiplied by 100.
Table 30. Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests. This
table collects information regarding alcohol- and drug-related arrests.
Table 31. Social Connectedness; Measure: Family Communications Around Drug and
Alcohol Use. This table provides information regarding the percent of youth reporting
having talked with a parent and the percent of parents reporting that they have talked to
their child around alcohol and drug use.
Table 32. Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or
Listening to a Prevention Message. This table collects information regarding the percent
of youth reporting having been exposed to prevention message.
Table 33. Individual-Based Programs and Strategies; Measure: Number of Persons
Served By Age, Gender, Race, and Ethnicity. This table provides information on the
number of persons served by individual-based programs and strategies. This includes
practices and strategies with identifiable goals designed to change behavioral outcomes
among a definable population or within a definable geographic area.
Table 34. Population-Based Programs And Strategies; Measure: Number of Persons
Served By Age, Gender, Race, And Ethnicity. This table provides information regarding
the number of persons by age, gender, race, and ethnicity that participated in populationbased programs. Population-based programs and strategies include planned and
deliberate goal-oriented practices, procedures, processes, or activities that have
identifiable outcomes achieved with a sequence of steps subject to monitoring and
modification.
Table 35. Number of Persons Served by Type of Intervention. This table seeks to measure
information on access and capacity of intervention programs. Specifically, this form
collects information on the number of persons served by type of Intervention.
Interventions include activities, practices, procedures, processes, programs, services, and
strategies.
Table 36. Number of Evidence-Based Programs by Types of Intervention. This table
collects information on the number of evidence-based programs and strategies by type of
intervention.
Table 37. Total Number of Evidence-Based Programs and Total SAPTBG Dollars Spent
on Evidence-Based Programs/Strategies. This table collects the total number of
evidence-based programs and total SABG dollars spent on evidence-based
programs/strategies

•

Prevention Attachments A, B and C—Completing the State request for data substitution
application and the State substitution appeal forms (below): These forms should be
completed if a State wishes to substitute data collected through a State effort for the
prevention pre-populated National Outcome Measures (NOMs) on the NOMs Data
Collection and Reporting Forms. If the State is requesting substitutions for more than
one NOM, one application should be completed for all NOMs for which a substitution is
requested. A state may also appeal a decision that the State will not be allowed to
substitute pre-populated with the States data.

Table 16 – TREATMENT PERFORMANCE MEASURE
EMPLOYMENT\EDUCATION STATUS (From Admission to Discharge)
Most recent year for which data are available: _____________
Employment\Education Status – Clients employed or student (full-time or
part-time) (prior 30 days) at admission vs. discharge

Number of clients employed or student (full-time and part-time) [numerator]

Total number of clients with non-missing values on employment\student
status [denominator]

Percent of clients employed or student (full-time and part-time)

Admission
Clients (T1)

Discharge
Clients (T2)

State Description of Employment\Education Status Data Collection (Table 16)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Employment\Education Data Collection (Table 16):
States should detail exactly how this information is collected. Where data and methods
vary from interim standard, variance should be described.

DATA SOURCE

What is the source of data for table 16 (select all that apply):
□ Client self-report □ Client self-report confirmed by another source→ □ collateral source
□ Administrative data source □ Other Specify ___________________

EPISODE OF CARE

How is the admission/discharge basis defined for table 16 (Select one) □ Admission is on
the first date of service, prior to which no service has been received for 30 days AND
discharge is on the last date of service, subsequent to which no service has been received
for 30 days
□ Admission is on the first date of service in a Program/Service Delivery Unit and
Discharge is on the last date of service in a Program/Service Delivery Unit
□ Other Specify ___________________________________________
_________________________________________________________
How was discharge data collected for table 16 (select all that apply)
□ Not applicable, data reported on form is collected at time period other than discharge→
Specify:
□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months
Post- □ admission □ discharge □ other ______
□ Discharge data is collected for the census of all (or almost all) clients who were admitted
to treatment □ Discharge data is collected for a sample or all clients who were admitted to
treatment □ Discharge records are directly collected (or in the case of early dropouts) are
created for all (or almost all) clients who were admitted to treatment
□ Discharge records are not collected for approximately ___ % of clients who were
admitted for treatment
Was the admission and discharge data linked for table 16 (select all that apply):
□ Yes, all clients at admission were linked with discharge data using an Unique Client
Identifier (UCID)
Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □
Social Security Number (SSN) □ Unique client ID based on fixed client characteristics
(such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □
Provider-entity-specific unique ID
□ No, State Management Information System does not utilize UCID that allows
comparison of admission and discharge data on a client specific basis (data developed on a
cohorts basis) or State relied on other data sources for post admission data □ No, admission
and discharge records were matched using probabilistic record matching.
If data is not reported, why is State unable to report (select all that apply):
□ Information is not collected at admission □ Information is not collected at discharge □
Information is not collected by the categories requested □ State collects information on the
indicator area but utilizes a different measure.
State must provide time-framed plans for capturing employment\student status data on all
clients, if data is not currently available. Plans should also discuss barriers, resource needs
and estimates of cost.

DISCHARGE DATA
COLLECTION

RECORD LINKING

IF DATA IS UNAVAILABLE

DATA PLANS IF DATA IS NOT
AVAILABLE

Table 17–TREATMENT PERFORMANCE MEASURE
STABILITY OF HOUSING (From Admission to Discharge)
Most recent year for which data are available: _____________
Clients living in a stable living situation (prior 30 days) at admission vs. discharge

Number of clients living in a stable situation [numerator]
Total number of clients with non-missing values on living arrangements [denominator]
Percent of clients in a stable living situation

Admission
Clients (T1)

Discharge
Clients
(T2)

Table 18– TREATMENT PERFORMANCE MEASURE
CRIMINAL JUSTICE INVOLVEMENT (From Admission to Discharge)
Most recent year for which data are available: _____________
Clients without arrests (any charge) (prior 30 days) at admission vs. discharge

Number of Clients without arrests [numerator]
Total number of clients with non-missing values on arrests [denominator]
Percent of clients without arrests

Admission
Clients
(T1)

Discharge
Clients
(T2)

State Description of Criminal Involvement Data Collection (Table 18)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Criminal Involvement Data Collection (Table 18):
States should detail exactly how this information is collected. Where data and methods
vary from interim standard, variance should be described.

DATA SOURCE

What is the source of data for table 18(select all that apply):
□ Client self-report □ Client self-report confirmed by another source→ □ collateral
source □ Administrative data source □ Other Specify ___________________
How is the admission/discharge basis defined for table 18 (Select one) □ Admission is on
the first date of service, prior to which no service has been received for 30 days AND
discharge is on the last date of service, subsequent to which no service has been received
for 30 days
□ Admission is on the first date of service in a Program/Service Delivery Unit and
Discharge is on the last date of service in a Program/Service Delivery Unit
□ Other Specify ___________________________________________
_________________________________________________________

EPISODE OF CARE

DISCHARGE DATA
COLLECTION

RECORD LINKING

IF DATA IS UNAVAILABLE

DATA PLANS IF DATA IS
NOT AVAILABLE

How was discharge data collected for table 18 (select all that apply)
□ Not applicable, data reported on form is collected at time period other than discharge→
Specify:
□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months
Post- □ admission □ discharge □ other ______
□ Discharge data is collected for the census of all (or almost all) clients who were
admitted to treatment □ Discharge data is collected for a sample or all clients who were
admitted to treatment □ Discharge records are directly collected (or in the case of early
dropouts) are created for all (or almost all) clients who were admitted to treatment
□ Discharge records are not collected for approximately ___ % of clients who were
admitted for treatment
Was the admission and discharge data linked for table 18 (select all that apply):
□ Yes, all clients at admission were linked with discharge data using an Unique Client
Identifier (UCID)
Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □
Social Security Number (SSN) □ Unique client ID based on fixed client characteristics
(such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □
Provider-entity-specific unique ID
□ No, State Management Information System does not utilize UCID that allows
comparison of admission and discharge data on a client specific basis (data developed on a
cohorts basis) or State relied on other data sources for post admission data □ No,
admission and discharge records were matched using probabilistic record matching.

If data is not reported, why is State unable to report (select all that apply): □ Information
is not collected at admission □ Information is not collected at discharge □ Information is
not collected by the categories requested □ State collects information on the indicator area
but utilizes a different measure.
State must provide time-framed plans for capturing criminal justice involvement status
data on all clients, if data is not currently available. Plans should also discuss barriers,
resource needs and estimates of cost.

Table 19 – PERFORMANCE MEASURE
CHANGE IN ABSTINENCE – ALCOHOL USE (From Admission to Discharge)
Most recent year for which data are available: _____________
Alcohol Abstinence – Clients with no alcohol use (all clients regardless of primary problem) (use
Alcohol Use in last 30 days field) at admission vs. discharge.

Number of clients abstinent from alcohol [numerator]
Total number of clients with non-missing values on “used any alcohol” variable [denominator]
Percent of clients abstinent from alcohol
(1) If State does not have a "used any alcohol" variable, calculate instead using frequency of use
variables for all primary, secondary, or tertiary problem codes in which the coded problem is Alcohol
(e.g. ,TEDS Code 02)

Admission
Clients
(T1)

Discharge
Clients
(T2)

State Description of Alcohol Use Data Collection (Table 19)
STATE
CONFORMANCE TO
INTERIM STANDARD

State Description of Alcohol Use Data Collection (Table 19):
State should detail exactly how this information is collected. Where data and methods
vary from interim standard, variance should be described.

DATA SOURCE

What is the source of data for table 19 (select all that apply):
□ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood
test or other biological assay □ collateral source
□ Administrative data source □ Other Specify ___________________
How is the admission/discharge basis defined for table 19 (Select one) □ Admission is on
the first date of service, prior to which no service has been received for 30 days AND
discharge is on the last date of service, subsequent to which no service has been received
for 30 days
□ Admission is on the first date of service in a Program/Service Delivery Unit and
Discharge is on the last date of service in a Program/Service Delivery Unit
□ Other Specify ___________________________________________
How was discharge data collected for table 19 (select all that apply)
□ Not applicable, data reported on form is collected at time period other than discharge→
Specify:
□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months
Post- □ admission □ discharge □ other ______
□ Discharge data is collected for the census of all (or almost all) clients who were
admitted to treatment □ Discharge data is collected for a sample or all clients who were
admitted to treatment □ Discharge records are directly collected (or in the case of early
dropouts) are created for all (or almost all) clients who were admitted to treatment
□ Discharge records are not collected for approximately ___ % of clients who were
admitted for treatment
Was the admission and discharge data linked for table 19 (select all that apply):
□ Yes, all clients at admission were linked with discharge data using an Unique Client
Identifier (UCID)
Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □
Social Security Number (SSN) □ Unique client ID based on fixed client characteristics
(such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □
Provider-entity-specific unique ID
□ No, State Management Information System does not utilize UCID that allows
comparison of admission and discharge data on a client specific basis (data developed on a
cohorts basis) or State relied on other data sources for post admission data □ No,
admission and discharge records were matched using probabilistic record matching.

EPISODE OF CARE

DISCHARGE DATA
COLLECTION

RECORD LINKING

IF DATA IS
UNAVAILABLE

DATA PLANS IF
DATA IS NOT
AVAILABLE

If data is not reported, why is State unable to report (select all that apply): □ Information
is not collected at admission □ Information is not collected at discharge □ Information is
not collected by the categories requested □ State collects information on the indicator area
but utilizes a different measure.
State must provide time-framed plans for capturing abstinence - alcohol use status data on
all clients, if data is not currently available. Plans should also discuss barriers, resource
needs and estimates of cost.

Table 20 – PERFORMANCE MEASURE
CHANGE IN ABSTINENCE -- OTHER DRUG USE (From Admission to Discharge)
Most recent year for which data are available: _____________

Admission
Discharge
Drug Abstinence – Clients with no drug use (all clients regardless of primary problem) (use Any
Clients (T1)
Clients
Drug Use in last 30 days field) at admission vs. discharge.
(T2)
Number of Clients abstinent from illegal drugs [numerator]
Total number of clients with non-missing values on “used any drug” variable [denominator]
Percent of clients abstinent from drugs
(2) If State does not have a "used any drug" variable, calculate instead using frequency of use variables for all primary,
secondary, or tertiary problem codes in which the coded problem is Drugs (e.g., TEDS Codes 03-20)

State Description of Other Drug Use Data Collection (Table 20)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Other Drug Use Data Collection (Table 20):
States should detail exactly how this information is collected. Where data and methods
vary from interim standard, variance should be described.

DATA SOURCE

What is the source of data for table 20 (select all that apply):
□ Client self-report □ Client self-report confirmed by another source→ □ urinalysis,
blood test or other biological assay □ collateral source
□ Administrative data source □ Other Specify ___________________
How is the admission/discharge basis defined for table 20 (Select one) □ Admission is on
the first date of service, prior to which no service has been received for 30 days AND
discharge is on the last date of service, subsequent to which no service has been received
for 30 days
□ Admission is on the first date of service in a Program/Service Delivery Unit and
Discharge is on the last date of service in a Program/Service Delivery Unit
□ Other Specify ___________________________________________
How was discharge data collected for table 20 (select all that apply)
□ Not applicable, data reported on form is collected at time period other than discharge→
Specify:
□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months
Post- □ admission □ discharge □ other ______
□ Discharge data is collected for the census of all (or almost all) clients who were
admitted to treatment □ Discharge data is collected for a sample or all clients who were
admitted to treatment □ Discharge records are directly collected (or in the case of early
dropouts) are created for all (or almost all) clients who were admitted to treatment
□ Discharge records are not collected for approximately ___ % of clients who were
admitted for treatment
Was the admission and discharge data linked for table 20 (select all that apply):
□ Yes, all clients at admission were linked with discharge data using an Unique Client
Identifier (UCID)
Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □
Social Security Number (SSN) □ Unique client ID based on fixed client characteristics
(such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □
Provider-entity-specific unique ID
□ No, State Management Information System does not utilize UCID that allows
comparison of admission and discharge data on a client specific basis (data developed on a
cohorts basis) or State relied on other data sources for post admission data □ No,
admission and discharge records were matched using probabilistic record matching.

EPISODE OF CARE

DISCHARGE DATA
COLLECTION

RECORD LINKING

IF DATA IS UNAVAILABLE

DATA PLANS IF DATA IS
NOT AVAILABLE

If data is not reported, why is State unable to report (select all that apply): □ Information
is not collected at admission □ Information is not collected at discharge □ Information is
not collected by the categories requested □ State collects information on the indicator area
but utilizes a different measure.
State must provide time-framed plans for capturing abstinence – drug use status data on all
clients, if data is not currently available. Plans should also discuss barriers, resource needs
and estimates of cost.

Table 21 – PERFORMANCE MEASURE
CHANGE IN SOCIAL SUPPORT OF RECOVERY (From Admission to Discharge)
Most recent year for which data are available: _____________
Social Support of Recovery – Clients participating in self-help groups (e.g., AA, NA,
etc.) (prior 30 days) at admission vs. discharge
Number of clients participating in self-help (AA NA meetings attended, etc.)
[numerator]
Total number of Admission and Discharge clients with non-missing values on selfhelp activities [denominator]
Percent of clients participating in self-help activities

Admission
Clients
(T1)

Discharge
Clients
(T2)

State Description of Social Support of Recovery Data Collection (Table 21)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Social Support of Recovery Data Collection (Table 21):
States should detail exactly how this information is collected. Where data and methods vary
from interim standard, variance should be described.

DATA SOURCE

What is the source of data for table 21 (select all that apply):
□ Client self-report □ Client self-report confirmed by another source→
□ collateral source □ Administrative data source
□ Other Specify ___________________
How is the admission/discharge basis defined for table 21 (Select one) □ Admission is on the
first date of service, prior to which no service has been received for 30 days AND discharge is
on the last date of service, subsequent to which no service has been received for 30 days
□ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is
on the last date of service in a Program/Service Delivery Unit
□ Other Specify ___________________________________________
How was discharge data collected for table 21 (select all that apply)
□ Not applicable, data reported on form is collected at time period other than discharge→
Specify:
□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post□ admission □ discharge □ other ______
□ Discharge data is collected for the census of all (or almost all) clients who were admitted to
treatment □ Discharge data is collected for a sample or all clients who were admitted to
treatment □ Discharge records are directly collected (or in the case of early dropouts) are
created for all (or almost all) clients who were admitted to treatment
□ Discharge records are not collected for approximately ___ % of clients who were admitted for
treatment
Was the admission and discharge data linked for table 21 (select all that apply):
□ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier
(UCID)
Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social
Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of
birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific
unique ID
□ No, State Management Information System does not utilize UCID that allows comparison of
admission and discharge data on a client specific basis (data developed on a cohorts basis) or
State relied on other data sources for post admission data □ No, admission and discharge
records were matched using probabilistic record matching.
If data is not reported, why is State unable to report (select all that apply): □ Information is not
collected at admission □ Information is not collected at discharge □ Information is not collected
by the categories requested □ State collects information on the indicator area but utilizes a
different measure.

EPISODE OF CARE

DISCHARGE DATA
COLLECTION

RECORD LINKING

IF DATA IS UNAVAILABLE

DATA PLANS IF DATA IS
NOT AVAILABLE

State must provide time-framed plans for capturing self-help participation status data on all
clients, if data is not currently available. Plans should also discuss barriers, resource needs and
estimates of cost.

Table 22: RETENTION
Length of Stay (in Days) of Clients Completing Treatment
Most recent year for which data are available: _____________
STATE:

LENGTH OF STAY
LEVEL OF CARE

AVERAGE (MEAN)

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

MEDIAN (MEDIAN)

INTERQUARTILE RANGE

T ABLE 23– SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: R EDUCED M ORBIDITY - ABSTINENCE FROM DRUG USE /ALCOHOL
USE
M EASURE : 30-DAY USE
A.
Measure

1. 30-day
Alcohol Use

B.
Question/Response

C.
Pre-populated
Data

D.
Approved
Substitute
Data

Source Survey Item: NSDUH Questionnaire. “Think specifically about
the past 30 days, that is, from [DATEFILL] through today. During the
past 30 days, on how many days did you drink one or more drinks of an
alcoholic beverage?” [Response option: Write in a number between 0 and
30.]
Outcome Reported: Percent who reported having used alcohol during
the past 30 days.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
2. 30-day
Source Survey Item: NSDUH Questionnaire: “During the past 30 days,
Cigarette Use
that is, since [DATEFILL], on how many days did you smoke part or all
of a cigarette?” [Response option: Write in a number between 0 and 30.]
Outcome Reported: Percent who reported having smoked a cigarette
during the past 30 days.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
3. 30-day Use
Source Survey Item: NSDUH Questionnaire: “During the past 30 days,
of Other
that is, since [DATEFILL], on how many days did you use [other
Tobacco
tobacco products]†?” [Response option: Write in a number between 0 and
30.]
Products
Outcome Reported: Percent who reported having used a tobacco product
other than cigarettes during the past 30 days, calculated by combining
responses to questions about individual tobacco products (snuff, chewing
tobacco, pipe tobacco).
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
4. 30-day Use
Source Survey Item: NSDUH Questionnaire: “Think specifically about
of Marijuana
the past 30 days, from [DATEFILL] up to and including today. During
the past 30 days, on how many days did you use marijuana or hashish?”
[Response option: Write in a number between 0 and 30.]
Outcome Reported: Percent who reported having used marijuana or
hashish during the past 30 days.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
5. 30-day Use
Source Survey Item: NSDUH Questionnaire: “Think specifically about
of Illegal Drugs the past 30 days, from [DATEFILL] up to and including today. During
Other Than
the past 30 days, on how many days did you use [any other illegal
Marijuana
drug]‡?”
Outcome Reported: Percent who reported having used illegal drugs
other than marijuana or hashish during the past 30 days, calculated by
combining responses to questions about individual drugs (heroin, cocaine,
stimulants, hallucinogens, inhalants, prescription drugs used without
doctors’ orders).
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
†
NSDUH asks separate questions for each tobacco product. The number provided combines responses to all questions about
tobacco products other than cigarettes.
‡
NSDUH asks separate questions for each illegal drug. The number provided combines responses to all questions about illegal
drugs other than marijuana or hashish.

T ABLE 24 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: R EDUCED M ORBIDITY - ABSTINENCE FROM DRUG USE /ALCOHOL
USE
M EASURE : P ERCEPTION OF R ISK/H ARM OF USE
A.
Measure

B.
Question/Response

1. Perception of
Risk From
Alcohol

Source Survey Item: NSDUH Questionnaire: “How much do people risk
harming themselves physically and in other ways when they have five or
more drinks of an alcoholic beverage once or twice a week?” [Response
options: No risk, slight risk, moderate risk, great risk]
Outcome Reported: Percent reporting moderate or great risk.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
Source Survey Item: NSDUH Questionnaire: “How much do people risk
harming themselves physically and in other ways when they smoke one
or more packs of cigarettes per day?” [Response options: No risk, slight
risk, moderate risk, great risk]
Outcome Reported: Percent reporting moderate or great risk.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
Source Survey Item: NSDUH Questionnaire: “How much do people risk
harming themselves physically and in other ways when they smoke
marijuana once or twice a week?” [Response options: No risk, slight risk,
moderate risk, great risk]
Outcome Reported: Percent reporting moderate or great risk.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009

2. Perception of
Risk From
Cigarettes

3. Perception of
Risk From
Marijuana

C.
Pre-populated
Data

D.
Approved
Substitute
Data

T ABLE 25 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: R EDUCED M ORBIDITY - ABSTINENCE FROM DRUG USE /ALCOHOL
USE
M EASURE : AGE OF F IRST USE
A.
Measure

1. Age at First
Use of Alcohol

B.
Question/Response

C.
Pre-populated
Data

D.
Approved
Substitute
Data

Source Survey Item: NSDUH Questionnaire: “Think about the first time
you had a drink of an alcoholic beverage. How old were you the first time
you had a drink of an alcoholic beverage? Please do not include any time
when you only had a sip or two from a drink.” [Response option: Write in
age at first use.]
Outcome Reported: Average age at first use of alcohol.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
2. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the
Use of
first time you smoked part or all of a cigarette?” [Response option: Write
Cigarettes
in age at first use.]
Outcome Reported: Average age at first use of cigarettes.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
3. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the
Use of Tobacco first time you used [any other tobacco product]†?” [Response option:
Products Other Write in age at first use.]
Than Cigarettes Outcome Reported: Average age at first use of tobacco products other
than cigarettes.
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
4. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the
Use of
first time you used marijuana or hashish?” [Response option: Write in age
Marijuana or
at first use.]
Outcome Reported: Average age at first use of marijuana or hashish.
Hashish
Ages 12–17 - FFY 2009
Ages 18+ - FFY 2009
5. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the
Use of Illegal
first time you used [other illegal drugs]‡?” [Response option: Write in age
Drugs Other
at first use.]
Outcome Reported: Average age at first use of other illegal drugs.
Than
Marijuana or
Ages 12–17 - FFY 2009
Hashish
Ages 18+ - FFY 2009
†
The question was asked about each tobacco product separately, and the youngest age at first use was taken as the measure.
‡
The question was asked about each drug in this category separately, and the youngest age at first use was taken as the measure.

T ABLE 26 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: R EDUCED M ORBIDITY - ABSTINENCE FROM DRUG USE /ALCOHOL
USE
M EASURE : P ERCEPTION OF DISAPPROVAL /ATTITUDES
A.
Measure

B.
Question/Response

1. Disapproval of
Cigarettes

Source Survey Item: NSDUH Questionnaire: “How do you feel about
someone your age smoking one or more packs of cigarettes a day?”
[Response options: Neither approve nor disapprove, somewhat
disapprove, strongly disapprove]
Outcome Reported: Percent somewhat or strongly disapproving.
Ages 12–17 - FFY 2009
Source Survey Item: NSDUH Questionnaire: “How do you think your
close friends would feel about you smoking one or more packs of
cigarettes a day?” [Response options: Neither approve nor disapprove,
somewhat disapprove, strongly disapprove]
Outcome Reported: Percent reporting that their friends would
somewhat or strongly disapprove.
Ages 12–17 - FFY 2009
Source Survey Item: NSDUH Questionnaire: “How do you feel about
someone your age trying marijuana or hashish once or twice?”
[Response options: Neither approve nor disapprove, somewhat
disapprove, strongly disapprove]
Outcome Reported: Percent somewhat or strongly disapproving.
Ages 12–17 - FFY 2009
Source Survey Item: NSDUH Questionnaire: “How do you feel about
someone your age using marijuana once a month or more?” [Response
options: Neither approve nor disapprove, somewhat disapprove,
strongly disapprove]
Outcome Reported: Percent somewhat or strongly disapproving.
Ages 12–17 - FFY 2009
Source Survey Item: NSDUH Questionnaire: “How do you feel about
someone your age having one or two drinks of an alcoholic beverage
nearly every day?” [Response options: Neither approve nor disapprove,
somewhat disapprove, strongly disapprove]
Outcome Reported: Percent somewhat or strongly disapproving.
Ages 12–17 - FFY 2009

2. Perception of
Peer Disapproval
of Cigarettes

3. Disapproval of
Using Marijuana
Experimentally

4. Disapproval of
Using Marijuana
Regularly

5. Disapproval of
Alcohol

C.
Pre-populated
Data

D.
Approved
Substitute
Data

T ABLE 27 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: E MPLOYMENT /E DUCATION
M EASURE : P ERCEPTION OF W ORKPLACE P OLICY
A.
Measure

B.
Question/Response

Perception of
Workplace
Policy

Source Survey Item: NSDUH Questionnaire: “Would you be more or less likely
to want to work for an employer that tests its employees for drug or alcohol use
on a random basis? Would you say more likely, less likely, or would it make no
difference to you?” [Response options: More likely, less likely, would make no
difference]
Outcome Reported: Percent reporting that they would be more likely to work
for an employer conducting random drug and alcohol tests.
Ages 15–17 - FFY 2009
Ages 18+ - FFY 2009

C.
Prepopulated
Data

D.
Approved
Substitute
Data

C.
Prepopulated
Data

D.
Approved
Substitute
Data

T ABLE 28– SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: E MPLOYMENT /E DUCATION
M EASURE : AVERAGE DAILY SCHOOL ATTENDANCE R ATE
A.
Measure

Average
Daily School
Attendance
Rate

B.
Source

Source: National Center for Education Statistics, Common Core of Data: The
National Public Education Finance Survey available for download at
http://nces.ed.gov/ccd/stfis.asp
Measure calculation: Average daily attendance (NCES defined) divided by
total enrollment and multiplied by 100.
FFY 2009

T ABLE 29 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: C RIME AND C RIMINAL J USTICE
M EASURE : ALCOHOL -R ELATED T RAFFIC F ATALITIES
A.
Measure

AlcoholRelated Traffic
Fatalities

B.
Source

C.
Pre-populated
Data

D.
Approved
Substitute
Data

C.
Pre-populated
Data

D.
Approved
Substitute
Data

Source: National Highway Traffic Safety Administration Fatality
Analysis Reporting System
Measure calculation: The number of alcohol-related traffic fatalities
divided by the total number of traffic fatalities and multiplied by 100.
FFY 2009

T ABLE 30 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: C RIME AND C RIMINAL J USTICE
M EASURE : ALCOHOL - AND DRUG -R ELATED ARRESTS
A.
Measure

Alcohol- and
Drug-Related
Arrests

B.
Source

Source: Federal Bureau of Investigation Uniform Crime Reports
Measure calculation: The number of alcohol- and drug-related arrests
divided by the total number of arrests and multiplied by 100.
FFY 2009

T ABLE 31 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: SOCIAL C ONNECTEDNESS
M EASURE : F AMILY C OMMUNICATIONS AROUND DRUG AND ALCOHOL USE
A.
Measure

1. Family
Communications
Around Drug and
Alcohol Use
(Youth)

2. Family
Communications
Around Drug and
Alcohol Use
(Parents of
children aged 12–
17)

B.
Question/Response

C.
Pre-populated
Data

D.
Approved
Substitute
Data

Source Survey Item: NSDUH Questionnaire: “Now think about the
past 12 months, that is, from [DATEFILL] through today. During the
past 12 months, have you talked with at least one of your parents about
the dangers of tobacco, alcohol, or drug use? By parents, we mean
either your biological parents, adoptive parents, stepparents, or adult
guardians, whether or not they live with you.” [Response options: Yes,
No]
Outcome Reported: Percent reporting having talked with a parent.
Ages 12–17 - FFY 2009
Source Survey Item: NSDUH Questionnaire: “During the past 12
months, how many times have you talked with your child about the
dangers or problems associated with the use of tobacco, alcohol, or
other drugs?Ӡ [Response options: 0 times, 1 to 2 times, a few times,
many times]
Outcome Reported: Percent of parents reporting that they have talked
to their child.
Ages 18+ - FFY 2009

†

NSDUH does not ask this question of all sampled parents. It is a validation question posed to parents of 12- to 17-year-old
survey respondents. Therefore, the responses are not representative of the population of parents in a State. The sample sizes are
often too small for valid reporting.

T ABLE 32 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: R ETENTION
M EASURE : P ERCENTAGE OF YOUTH SEEING , R EADING , W ATCHING , OR L ISTENING TO A P REVENTION M ESSAGE
Measure

Exposure to
Prevention
Messages

Question/Response

Pre-populated
Data

Approved
Substitute
Data

Source Survey Item: NSDUH Questionnaire: “During the past 12
months, do you recall [hearing, reading, or watching an advertisement
about the prevention of substance use]†?”
Outcome Reported: Percent reporting having been exposed to
prevention message.
Ages 12–17 - FFY 2009
†
This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within
a specific context

Tables 33-37 – Reporting Period
Reporting Period - Start and End Dates for Information Reported on Tables 33, 34, 35, 36, and 37.
Instructions for completing reporting Start and End Dates
The following chart is for collecting information on the reporting periods for the data entered in Tables 33, 34, 35, 36 and 37.
See: The instructions for and the data entered in Tables 33, 34, 35, 36 and 37.
Rows 1 through 5 each correspond to a single form in the current year’s application among the following five tables: 33, 34, 35,
36 and 37.
Column A – Enter the reporting period start date.
Column B – Enter the reporting period end date.
The date format to be entered in columns A and B should be month/day/year, as follows.
•
Month: enter 2 digits (e.g. January = 01; December = 12)
•
Day: enter 2 digits (e.g. 1st of the month = 01; 15th of the month =15)
•
Year: enter all 4 digits (e.g., 2009)

Reporting Period Start and End Dates for Information Reported on Tables 33, 34, 35, 36 and 37
Please indicate the reporting period (start date and end date totaling 12 months by the State)
for each of the following forms:
A. Reporting Period
B. Reporting Period
Tables
Start Date
End Date
1. Ta b le 33
Individual-Based Programs and
Strategies – Number of Persons Served
by Age, Gender, Race, and Ethnicity

mm/dd/yyyy

mm/dd/yyyy

2. Ta b le 34
Population-Based Programs and
Strategies – Number of Persons Served
by Age, Gender, Race, and Ethnicity

mm/dd/yyyy

mm/dd/yyyy

3. Ta b le 35 (Optional)
Number of Persons Served by Type of
Intervention

mm/dd/yyyy

mm/dd/yyyy

4. Ta b le 36
Number of Evidence-Based Programs
and Strategies by Type of Intervention

mm/dd/yyyy

mm/dd/yyyy

5. Ta b le 37
Total Number of Evidence-Based
Programs and Total SAPT BG Dollars
Spent on Evidence-Based
Programs/Strategies

Da ta s u bm itte d o n Ta b le
37 m us t c o rre s p o n d to
th e re p o rtin g p e rio d s ta rt
d a te u s e d fo r Ta b le 36

Da ta s u bm itte d o n Ta b le
37 m us t c o rre s p o n d to
th e re p o rtin g p e rio d e n d
d a te u s e d fo r Ta b le 36

General Questions Regarding Prevention NOMS Reporting
Question 1: Describe the data collection system you used to collect the NOMs data (e.g., MDS, DbB, KIT Solutions, manual
process).

Question 2: Describe how your State’s data collection and reporting processes record a participant’s race, specifically for
participants who are more than one race.
Indicate whether the State added those participants to the number for each applicable racial category or whether the State added
all those participants to the More Than One Race subcategory.

Table 33 – SUBSTANCE ABUSE P REVENTION Individual-Based Programs and Strategies—Number of
Persons Served by Age, Gender, Race, and Ethnicity
Category
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino

Total

Table 34 – SUBSTANCE ABUSE P REVENTION Population-Based Programs and Strategies—Number of
Persons Served by Age, Gender, Race, and Ethnicity
Category
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino

Total

Table 35 (Optional) – SUBSTANCE ABUSE P REVENTION Number of Persons Served by Type of Intervention
Number of Persons Served by Individual- or Population-Based Program
or Strategy

Intervention Type
1. Universal Direct
2. Universal Indirect
3. Selective
4. Indicated
5. Total

A.
Individual-Based
Programs and Strategies

B.
Population-Based Programs and
Strategies
N/A

N/A
N/A
N/A

Table 36 – SUBSTANCE ABUSE P REVENTION Evidence-Based Programs and Strategies by Type of Intervention

1.

Describe the process the State will use to implement the guidelines included in the above definition.

2.

Describe how the State collected data on the number of programs and strategies. What is the source of the data?

Table 36 – SUBSTANCE ABUSE P REVENTION Number of Evidence-Based Programs and Strategies by Type of Intervention
Number of Programs and Strategies by Type of Intervention
A.
Universal
Direct
1. Number of Evidence-Based
Programs and Strategies Funded
2. Total number of Programs and
Strategies Funded
3. Percent of Evidence-Based
Programs and Strategies

B.
Universal
Indirect

C.
Universal
Total

D.
Selective

E.
Indicated

F.
Total

Table 37 – Total SUBSTANCE ABUSE P REVENTION Number of Evidence Based Programs and Total SAPT BG Dollars Spent
on SUBSTANCE ABUSE P REVENTION Evidence-Based Programs/Strategies
Total Number of Evidence-Based Programs/Strategies for
IOM Category below:

Total SAPT Block Grant $Dollars Spent on evidencebased Programs/Strategies

Universal Direct

Total #

$

Universal Indirect

Total #

$

Selective

Total #

$

Indicated

Total #

$

Total EBPs:

Total Dollars Spent: $

Pr evention Attachments A and B – Completing the State r equest for data substitution application and the State
substitution appeal for ms (below):
These for ms should be completed if a State wishes to substitute data collected thr ough a State effor t for the pr evention
pr e-populated National Outcome Measur es (NOMs) on the NOMs Data Collection and Repor ting For ms. If the State is
r equesting substitutions for mor e than one NOM, one application should be completed for all NOMs for which a
substitution is r equested. A state may also appeal a decision that the State will not be allowed to substitute pr e-populated
with the States data.
Prevention Attachment A:
Application Form to Substitute Data
1. CONTACT INFORMATION
State/Territory/tribe:
Name of the applicant (first and last name):
Title:
 Mr.

 Ms.

 Dr.

 Other _____________________

State position:
Organization:
Department:
Mailing address:
E-mail address:
Telephone:
Fax:
2. MEASURE LABELS
Label of the National Outcome Measure (NOM) being replaced:

Label of the substituted measure (if not identical to the NOM):

3. Narrative Justification
Provide a brief description of the reasons for the substitution. Continue on the back of the page if necessary.

4. Data Source for Substituted Measure
Name of the agency or organization responsible for data collection:

Name of contact person at data collection agency/organization (first and last name):

E-mail address:
Telephone:
Most recent year for which data are available:
Is data collection repeated every year?
 Yes

 No (Indicate frequency of data collection.)______________________

Are trend data available?
 Yes (Indicate start year of trend data.)_________________________
What is the mode of data collection?

 Census

 No
 Survey (Please complete item 5.)

 Other (Please describe.)
5. SURVEY DESCRIPTION
(Skip if mode of data collection is not a survey.)
The following questions refer to the most recent implementation of the survey.
Date of data collection:
Sample size:
Sampling ratio (sample size divided by the size of the target population):

What type of sampling strategy was used to select respondents? (Please check one.)


Convenience sample (no statistical sampling techniques were used)



Probability sample (statistical sampling techniques were used)

The following four questions apply to probability samples only.
If the sample is stratified, please identify each stratum:

If cluster sampling was used, please identify the clustering unit(s):

If a multistage design was used, please identify the unit sampled at each stage:

Potential sources of bias in the sample design:

The following questions apply to all surveys.
Method of administration:

 Mail-in

 Telephone

 School-based: self-administered

 Self-administered: survey site other than a school

 Face-to-face

 Other (Please specify.)
Was the interview computer-assisted?  Yes

 No

Name of the survey instrument:
What was the survey response rate (i.e., multiply the number who took the survey/original sample size by 100)?

Were there validity and reliability tests of the survey items constituting the substitute measure?
 No
 Yes (Please describe reliability/validity study/studies.)

Are there any published validity/reliability studies for this instrument?
 No
 Yes (Please provide bibliographic information.)

6. DATASET SUBMISSION INFORMATION
Name of the data file(s) being submitted:

Description of data file(s) (Include format and size.):

For each data file, describe the content of the data records (e.g., “Each record contains all of the information for a single
individual.”):

Names of documentation files:

Description of documentation file(s):

Total number of files being submitted:

Prevention Attachment B

Prevention Attachment B:
Substitution Appeal Form
State/Territory/tribe:
Date substitution application submitted:
Date denial received:
Date appeal submitted:
1. CONTACT INFORMATION
Name of the applicant (first and last name):
 Mr.

 Ms.

 Dr.

 Other _____________________

Organization:

Department:

Mailing address:
E-mail address:
TELEPHONE:
FAX:
2. MEASURE(S) BEING APPEALED
National Outcome Measure(s) (NOM) being appealed:

Summarize SAMHSA’s reason(s) for the denial of the substitution:

3. RATIONALE FOR THE APPEAL
State the rationale for appealing SAMHSA’s decision:

Prevention Attachment B
4. ATTACH A COPY OF THE ORIGINAL SUBSTITUTION APPLICATION.

5. ADDITIONAL DATA OR ANALYSIS TO SUPPORT THE APPEAL.
Describe any additional data or analysis that supports the appeal:

P REVENTION ATTACHMENT C:
APPROVED SUBSTITUTE DATA SUBMISSION F ORM

Create a separate form for each data source.
G RANTEE AND C ONTACT I NFORMATION
State/Territory/tribe:
Name of contact person (first and last name):
 Mr.

 Ms.

 Dr.

 Other _____________________

Organization:
Department:
Mailing address:
E-mail address:
TELEPHONE:

DATE
Enter the date when the Application Form To Substitute Data was submitted:
If final approval was obtained after an appeal process, enter the date when the appeal was filed:

Enter the date when approval to submit alternative data was obtained:
M EASURE (S)
Enter the NOMs measure(s) for which State-generated data are being substituted:__________

FAX:

Table 38: (Optional Wor ksheet) Pr ogr am/Str ategy Detail for Computing the Total Number of Evidence-based
Pr ogr ams and Str ategies, and for Repor ting Total SAPT Block Gr ant Funds Spent on substance abuse pr evention
Evidence-Based Pr ogr ams and Str ategies.
1

2

Program/Strategy Name
Universal Direct

Total Number of
Evidence-based
Pr ogr ams and
Str ategies by
Inter vention

3
Total Costs of
Evidence
based Programs
and Strategies
for each IOM
Category

#

$

4
Total SAPT Block Grant Funds
Spent on Evidence-Based
Programs/Strategies

1.
2.
3.
4.
Subtotal
Universal Indirect
Programs and
Strategies
1.
2.
3.
4.
Subtotal
Selective Programs and
Strategies
1.
2.
3.
4.
Subtotal
Indicated Programs and
Strategies
1.
2.
3.
4.
Subtotal
Total Number of
(EBPs)/Strategies and
cost of these
EBPs/Strategies
Total SAPT Block Grant
substance abuse
prevention Dollars $
Spent on EvidenceBased Programs and
Strategies

$