Reporting

Uniform Application for the Community MH Services BG and SAPT BG Application Guidance and Instructions FY 2014-2015

2014_BGrepts_4-29-13 clean

Application

OMB: 0930-0168

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0930-0168 can be found here:

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Block Grant Reporting Section
FY 2014

CFDA 93.958 (Mental Health)

U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration

101

Table of Contents

A. Introduction
B. Implementation Report
MHBG Table 1 Priority Area and Annual Performance Indicators – Progress Report
C. State Agency Expenditure Reports
MHBG Table 2 (URS Table 7). State Agency Expenditure Report. .
MHBG Table 3 MHBG Expenditures By Service.
MHBG Table 4–Set-aside for Children’s Mental Health Services.
MHBG Table 5 (URS Table 8). Profile Of Mental Health Block Grant Expenditures For
Non-Direct Service Activities.
MHBG Table 6 (URS Table 10). – Statewide Entity Inventory.
MHBG Table 7 - Maintenance of Effort for State-wide Expenditures on Mental Health
Services
D. Population and Services Reports
MHBG Table 8A and MHBG Table 8b Profile of Clients by Type of Funding Support
(URS Tables 5A and 5B).
MHBG Table 9 (URS Table 1). Profile of the State Population by Diagnosis.
MHBG Table 10 (URS Table 12). State Mental Health Agency Profile.
MHBG Table 11A and MHBG Table 11B (URS Tables 2A and 2B) Profile of Persons
Served, All Programs by Age, Gender and Race/Ethnicity.
MHBG Table 12 (URS Table 3). Profile Of Persons Served In The Community Mental
Health Settings, State Psychiatric Hospitals And Other Settings
MHBG Tables 13A, 13B and 13C (NEW, URS Tables 14A and 14B). Profile of Persons
With SMI/SED Served By Age, Gender And Race/Ethnicity.
MHBG Table 14 (URS Table 5). Profile of Client Turnover. Performance Indicators and
Accomplishments
E: Performance Indicators and Accomplishments
MHBG Table 15 (URS Table 17). Profile of Adults with Serious Mental Illnesses
Receiving Specific Services During the Year. .
MHBG Table 16A (URS Table 4). Profile of Adult Clients By Employment Status.
MHBG Table 16B (URS Table 4A). Profile Of Adult Clients By Employment Status: By
Primary Diagnosis Reported.
MHBG Table 17 (URS Table 15). Living Situation Profile.
MHBG Table 18 (URS Table 19B). Profile of Change in School Attendance.
MHBG Table 19 (URS Table 9). Social Connectedness and Improved Functioning.
MHBG Table 20A (URS Table 11). Summary Profile of Client Evaluation of Care.

102

MHBG Table 20B (URS Table 11A). Consumer Evaluation of Care By Consumer
Characteristics: Race/Ethnicity.
MHBG Table 21 (URS Table 19A). Profile Of Criminal Justice Or Juvenile Justice
Involvement.
MHBG Table 22 (URS Table 16). Profile of Adults With Serious Mental Illnesses And
Children With Serious Emotional Disturbances Receiving Specific Services.
MHBG Table 23A (URS Table 20A). Profile of Non-Forensic (Voluntary and CivilInvoluntary) Patients Readmission to Any State Psychiatric Inpatient Hospital Within
30/180 Days of Discharge.
MHBG Table 23B (URS Table 20B). Profile of Forensic Patients Readmission to Any
State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge.
MHBG Table 24 (URS Table 21). Profile of Non-Forensic (Voluntary and CivilInvoluntary Patients) Readmission to Any Psychiatric Inpatient Care Unit (State Operated
or Other Psychiatric Inpatient Unit) within 30/180 Days of Discharge

103

Section 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 State
Fiscal Year (SFY) in the format provided in this guidance. The report will address the purposes for
which the MHBG were expended, the recipients of grant funds, and the authorized activities
conducted 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 are required to prepare and submit their respective reports utilizing SAMHSA’s Web
Block Grant Application System (BGAS). This report must be received by SAMHSA not later than
December 1 in order for State or Jurisdiction to receive its next grant. 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:

2015

Plan and Repor t Due Dates
Plan Due
Planning Per iod
Repor t Due
Date
Date
04/01/2013
07/01/2013 12/01/2013
06/30/2015
12/01/2014

2016

04/01/2015

Application for Feder al
fiscal year
2014

2017

07/01/2015 –
06/30/2017

12/01/2015
12/01/2016

Repor t Per iod
Last Completed
SFY
Last Completed
SFY
Last Completed
SFY
Last Completed
SFY

States are required to complete the Reporting Document. The Reporting Document is comprised of
the following sections:
Section B: Implementation Report - In this section, States 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 plan covering the last completed fiscal year.. The report should
also include a brief review of areas that the State identified in that Block Grant Plan as needing

104

improvement and changes that the State and Jurisdiction would propose to achieve the goals
established for the priorities.
Section C: State Agency Expenditure Reports - In this section, States should provide information
regarding expenditures for authorized activities and services for mental health.
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 MHBG 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 mental health services as well as any State- or Jurisdictionselected performance indicators.

105

B. Implementation Report
The information States entered into the performance indicator tables (Plan Table 1) in the planning
section of the 2014/2015 Community Mental Health Services Plan will automatically populate cells 1
– 6 in the progress report tables below. States are required to indicate whether each first-year
performance target/outcome measurement identified in the 2014/2015 Plan was “Achieved” or “Not
Achieved” in Cell 7, Report of Progress toward goal attainment. If a target was not achieved, a
detailed explanation must be provided as well as the remedial steps proposed to meet the target.
MHBG Table 1 Priority Area and Annual Performance Indicators – Progress Report
1. Priority Area:
1. Priority Type (SAP, SAT, MHP, MHS):
3. Population(s) (SMI, SED, PWWDC, IVDUs, HIV EIS, TB, OTHER):
4. Goal of the priority area:

5. Strategies to attain the goal:
6. Annual Performance Indicators to measure goal success:
Indicator #1:
a)

Baseline measurement (Initial data collected prior to the first-year target/outcome):

b) First-year target/outcome measurement (Progress – end of SFY 2014):
c) Second-year target/outcome measurement (Final – end of SFY 2015):
d)

Data source:

e) Description of data:
f)

Data issues/caveats that affect outcome measures:

7. Report of Progress toward goal attainment:
First-year target:

____ Achieved

_____ Not Achieved (If not achieved, explain why.)

Reason why target was not achieved, and changes proposed to meet target:

106

C. State Agency Expenditure Reports
Mental Health Services Block Grant Spending
States and Jurisdictions should provide information regarding MHBG and State funds expended for
authorized activities to prevent and treat mental illness during the last completed State fiscal year
(SFY). Please complete the tables described below. Please Note: Data for all tables contained in
the Uniform Reporting System (URS) will continue to be submitted into the URS data base
maintained by the URS Contractor.
•
•
•
•

•

MHBG Table 2 (URS Table 7). State Agency Expenditure Report. MHBG Table 2 provides
information on Mental Health Expenditures and Sources of Funding. This includes funding
from Medicaid, the MHBG. other federal funding sources, state, local and other funds.
MHBG Table 3 MHBG Expenditures By Service. MHBG Table 3 is to be used to report
MHBG expenditures by unduplicated individual and specific services.
MHBG Table 4–Set-aside for Children’s Mental Health Services. This table provides a
report of State-wide expenditures for children’s mental health services during the last
completed State fiscal year (SFY).
MHBG Table 5 (URS Table 8). Profile Of Mental Health Block Grant Expenditures For
Non-Direct Service Activities. MHBG Table 5 is used to report expenditures of MHBG funds
for non-direct service activities that are funded or conducted by the State Mental Health
Authority during the last completed State fiscal year (SFY).
MHBG Table 6 (URS Table 10). – Statewide Entity Inventory. This table reports payments
to recipients of MHBG funds including intermediaries, e.g., administrative service
organizations, and other organizations which provided mental health services during the last
completed State fiscal year.
MHBG Table 7 - Maintenance of Effort for State-wide Expenditures on Mental Health
Services. This table reports expenditures of all State-wide non-Federal expenditures for
authorized activities to prevent and treat mental illness during the last completed State fiscal
year (SFY).

107

MHBG Table 2 (URS Table 7): State Agency Expenditure Report
This table describes expenditures for public mental health services provided or funded by the State
mental health agency by source of funding.
MHBG Table 2

State Agency Expenditures

(Include ONLY funds expended by the executive branch agency administering the SA Block Grants and/or the MH Block Grant*
Report Period- From:

To:

State Identifier:
Sour ce of Funds
ACTIVITY
(See instructions for using Row
1.)

A.
Substance
Abuse Block
Gr ant

E. State
funds

F. Local
funds
(excluding
local
Medicaid)

G.
Other

Substance Abuse
Pr evention* and
Tr eatment

Pr egnant Women
and Women with
Dependent Childr en*

All Other

Primar y Pr evention**

Tuberculosis Ser vices

HIV Ear ly Inter vention
Ser vices

State Hospital

Mental
Health
Block
Gr ant.

C. Medicaid
(Federal,
State, and
local)

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

6. Other 24 Hour Car e

7. Ambulatory/Community Non24 Hour Car e

8. Administration (excluding
pr ogram / pr ovider level

9. Total

* Prevention other than primary prevention
** States may only use MH Block Grant funds to provide primary prevention services to the priority populations of adults

with serious mental illness and children with serious emotional disturbance.

108

MHBG Table 3 : MH Block Grant Expenditures by Service
MHBG Table 3

MHBG Block Grant Expenditures by Service

State Identifier:
Report Period-

From:

To:
Service

Unduplicated
Individuals

Unit
Type

Unit
Quantity

MHBG
Expenditures

Prevention and Wellness
Screening, Brief Intervention and Referral to Treatment (SBIRT)
Brief Motivational Interviewing
Screening and Brief Intervention for Tobacco Cessation
Parent Training
Facilitated Referral
Relapse Prevention/Wellness Recovery Support
Warm Line
Engagement Services
Assessment
Specialized Evaluations
Service Planning
Consumer/Family Education
Outreach
Outpatient Services
Individual Evidenced Based Therapies
Group Therapy
Family Therapy
Multi-family counseling
Consultation with Caregivers
Medication Services
Medication management
Pharmacotherapy
Laboratory Services
Community Support Services
Parent/Caregiver Support
Skill Building
Case management
Continuing care
Behavior management
Supported employment
Permanent supportive housing
Recovery housing
Therapeutic mentoring
Traditional healing services
Recovery Support Services
Peer Support
Recovery Support Coaching
Recovery Support Center Services
Supports for Self Directed Care
Other Supports

109

MHBG Table 3

MHBG Block Grant Expenditures by Service

State Identifier:
Report Period-

From:

To:
Service

Unduplicated
Individuals

Unit
Type

Unit
Quantity

MHBG
Expenditures

Personal care
Homemaker
Respite
Supported education
Transportation
Assisted Living
Recreational services
Trained Behavioral Health Interpreters
Interactive Communication Technology Devices
Intensive Support Services
Substance Abuse Intensive Outpatient (IOP)
Partial hospital
Assertive Community Treatment
Intensive home based services
Multi-systemic Therapy
Intensive Case Management
Out of Home Residential Services
Crisis residential/stabilization
Adult Substance Abuse Residential
Adult Mental Health Residential
Youth Substance Abuse Residential
Children's Residential Mental Health
Therapeutic foster care
Acute Intensive Services
Mobile crisis
Peer based crisis services
Urgent care
23 hr. observation bed
Inpatient detoxification
24/7 crisis hotline
Other (please list)

110

MHBG Table 4 : Set-Aside for Children’s Mental Health Services
MHBG Table 4:
State –wide Expenditures for Children’s Mental Health Services
State Identifier:
Report Period: From:
To:
Actual SFY 2008
Actual SFY 2014

States are required to not spend less than the amount expended in FY 2008.

111

MHBG Table 5 (URS Table 8): Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities
This table is used to describe the use of MHBG funds for non-direct service activities that are sponsored, or conducted, by the State Mental Health
Authority.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
MHBG Table 5
State Identifier:
Report Period- From:

Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities
To:

Service

Expenditures

MHA Technical Assistance Activities
MHA Planning Council Activities
MHA Administration
MHA Data Collection/Reporting
MHA Activities Other Than Those Above
Total Non-Direct Services
Comments on Data:

MHBG Table 6 (URS Table 10). Statewide Entity Inventory
MHBG Table 6

Statewide Entity Inventory

State Identifier:
Report Period- From:

To:
A

Entity
Number

Total

I-SATS
ID (for
SABG)

Area
Served
(Statewide
or SubState
Planning
Area)

Provider/Program
Name

Street
Address

City

State

Zip

Total
Block
Grant
Funds

$
$
$

Source of Funds
SA Block Grant
B
D
E

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

MH Block Grant
G

Pregnant
Women and
Women
with
Dependent
Children

Primary
Prevention

Early
Intervention
Services for
HIV

Adults
with
serious
mental
illness

Children with a
serious emotional
disturbance

Non-Direct
Service
Activities

$
$
$

113

MHBG Table 7 Maintenance of Effort for State Expenditures on Mental Health Services
MHBG Table 7:
Maintenance of Effort for State Expenditures on Mental Health Services
State Identifier:
Report Year:
Total Expenditures for State _____
Period

Expenditures

B1 (2009) + B2 (2010)
2

A
SFY 2011
(1)
SFY 2012
(2)
SFY 2013
(3)

Are the expenditure amounts reported in Column B “actual” expenditures for the State fiscal years involved?
FY 2011
FY 2012
FY 2013

Yes_____ No_____
Yes_____ No_____
Yes_____ No_____

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

D. Populations and Services Report
States are requested to provide information regarding individuals that are served by the state mental
health authority using MHBG Tables 8 through 14.
•

•
•
•

•

MHBG Table 8A and 8b Profile of Clients by Type of Funding Support. MHBG Tables 8A
and 8B provide the number of Female and Male clients by race and by ethnicity that have:
Medicaid Only, Non-Medicaid Sources, Both Medicaid and Non-Medicaid, and Status not
available.
MHBG Table 9 (URS Table 1). Profile of the State Population by Diagnosis. MHBG Table
9 provides the number of Adults with SMI and Children with SED in the reporting year and
in three years forward.
MHBG Table 10(URS Table 12) . State Mental Health Agency Profile. MHBG Table 10
provides the Populations covered in State hospitals and Community program in age
categories; 0-3, 4-17 and 18 and above.
MHBG Tables 11A and 11B (URS Tables 2A and 2B) Profile of Persons Served, All
Programs by Age, Gender and Race/Ethnicity. MHBG Tables 11A and 11B provide an
aggregate profile of unduplicated persons in the reporting year. The reporting year should be
the latest state fiscal year for which data are available. This profile is based on a client
receiving services in programs provided or funded by the state mental health agency. The
client profile takes into account all institutional and community services for all such
programs. States are to provide this information on all programs by age, gender,
race/ethnicity.
MHBG Table 12 (URS Table 3). Profile Of Persons Served In The Community Mental
Health Settings, State Psychiatric Hospitals And Other Settings. MHBG Table 12 provides an
aggregate profile of unduplicated persons in the reporting year for services funded through
the MHBG. The reporting year should be the latest state fiscal year for which data are
available. This profile is based on a client receiving services in programs provided or funded
by the MHBG. The client profile takes into account all institutional and community services
for all such programs. States are to provide this information on all programs by age, gender,
race/ethnicity.
MHBG Tables 13A,13B and 13C (URS Tables 14A and 14B). Profile of Persons With
SMI/SED Served By Age, Gender And Race/Ethnicity. Tables 13A, 13B and 13C request
counts for persons with SMI or SED using the definitions provided by the CMHS. MHBG
Tables 13A, 13B and 13C included individuals receiving services in programs provided or
funded by the state mental health agency. These tables count only clients who meet the
CMHS definition of SMI or SED. States should report using the Federal Definitions of SMI
and SED if they can report them, if not, please report using your state’s definitions of SMI
and SED and provide information in these tables describing your state’s definition.
MHBG Table 14 (URS Table 6). Profile of Client Turnover. MHBG Table 14 requests
information regarding the profile of client turnover in various out-of-home settings (e.g. state
hospitals, inpatient psychiatric hospitals, residential treatment centers). Information collected
by this table requests admissions, discharges, and length of stay.

115

MHBG Table 8A. Profile of Clients by Type of Funding Support (URS
Table 5A)
This table provides a summary of clients by Medicaid coverage. Since the focus of the reporting is on clients of the public mental health service delivery system, this table
focuses on the clientele serviced by public programs that are funded or operated by the State Mental Health Authority. Persons are to be counted in the Medicaid row if they
received a service reimbursable through Medicaid.
Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

MHBG Table 8A
Report Period- From:
State Identifier:

To:

Total
Female

Male

Not
Available

American Indian or Alaska Native
Total

Female

Male

Not Available

Asian
Female

Male

Black or African American
Not Available

Female

Male

Not Available

Medicaid (only Medicaid)
Non-Medicaid Sources (only)
People Served by Both Medicaid and
Non-Medicaid Sources
Medicaid Status Not Available
Total Served

Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their treatment, and
(4) Medicaid Status Not Available.
If a state is unable to unduplicate between people whose care is paid for by Medicaid only or Medicaid and other funds, then all data should be reported into the 'People Served
by Both Medicaid and Non-Medicaid Sources' and the 'People Served by Both includes people with any Medicaid' check box should be checked.

MHBG Table
8A (Con’t)
Report
Period- From:
To:
State
Identifier:
Native Hawaiian or Other
Pacific Islander
Female

Male

Medicaid
(only
Medicaid)
NonMedicaid
Sources
(only)
People
Served by
Both
Medicaid and
NonMedicaid
Sources
Medicaid
Status Not
Available
Total Served

(continued on next page)

Not
Available

Hispanic * use only if data for
MHBG Table 3b are not
available.

White

Female

Male

Not
Available

Female

Male

Not
Available

More Than One Race
Reported
Female

Male

Not
Available

Race Not Available

Female

Male

Not
Available

MHBG Table 8B. (URS Table 5B) Profile of Clients by Type of Funding Support
Of the total persons covered by Medicaid, please indicate the gender and number of persons who are Hispanic/Latino or not Hispanic/Latino. Total persons
covered by Medicaid would be the total indicated in MHBG Table 8A.

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.
MHBG Table 8B.
Report Period- From
State Identifier:

To:

Not Hispanic or Latino
Female

Male

Not
Available

Hispanic or Latino
Female

Ma
l

Not
Available

Hispanic or Latino
Origin Unknown
Female

Male

Not
Available

Total
Female

Male

Not
Available

Total

Medicaid Only
Non-Medicaid Only
People Served by Both Medicaid and NonMedicaid Sources
Medicaid Status Unknown
Total Served
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their
treatment, and (4) Medicaid Status Unknown.

118

MHBG Table 9 (URS Table 1). Profile of the State
Population by Diagnosis
This table summarizes the estimates of adults residing within the State with serious mental illness (SMI) and
children residing within the state with serious emotional disturbances (SED). The table calls for estimates for
two time periods, one for the report year and one for three years into the future. CMHS will provide this data to
States based on the standardized methodology developed and published in the Federal Register and the
State level estimates for both adults with SMI and children with SED.
MHBG Table 9
Report Year:
State Identifier:
Current Report Year

Adults with Serious Mental Illness (SMI)
Children with Serious Emotional Disturbances (SED)
Note: This Table will be completed for the States by CMHS.

Three Years Forward

MHBG Table 10 (URS Table 12): State Mental Health Agency Profile

The purpose of this profile is to obtain information that provides a context for the data provided in the tables. This profile covers the
populations served, services for which the state mental health agency is responsible, data reporting capacities, especially related to
duplication of numbers served as well as certain summary administrative information.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
MHBG Table 10
Report Year:
State Identifier:

Populations Served
1

Which of the following populations receive services operated or funded by the state mental health agency? Please
indicate if they are included in the data provided in the tables. (Check all that apply.)
Populations Covered
State Hospitals

Community Programs

Included in Data
State Hospitals

Community
Programs

1. Aged 0 to 3

2. Aged 4 to 17

3. Adults Aged 18 and over

4. Forensics
Comments on Data:

Do all of the adults and children served through the state mental health agency meet the Federal definitions of serious
mental illness and serious emotional disturbances?

2.a.

If no, please indicate the percentage of persons served for the reporting period who met the federal definitions of serious mental
illness and serious emotional disturbance?

2.a.1

Percent of adults meeting Federal definition of SMI:

2.a.2

Percentage of children/adolescents meeting Federal definition of SED

Co-Occurring Mental Health and Substance Abuse:

3.a.

What percentage of persons served by the SMHA for the reporting period have a dual diagnosis of mental illness and substance
abuse?

120

3.a.1
Percentage of adults served by the SMHA who also have a diagnosis of substance abuse problem:
3.a.2.

3.b.

Percentage of children/adolescents served by the SMHA who also have a diagnosis of substance abuse
problem:

What percentage of persons served for the reporting period who met the Federal definitions of adults with SMI and
children/adolescents with SED have a dual diagnosis of mental illness and substance abuse.

3.b.1
Percentage of adults meeting Federal definition of SMI who also have a diagnosis of substance abuse problem:
3.b.2.

3b.3

Percentage of children/adolescents meeting the Federal definition of SED who also have a diagnosis of
substance abuse problem:
Please describe how you calculate
and count the number of persons with
co-occurring disorders
State Mental Health Agency Responsibilities
a. Medicaid: Does the State Mental Health Agency have any of the following responsibilities for mental health services provided
through Medicaid? (Check All that Apply)

1. State Medicaid Operating Agency
2. Setting Standards
3. Quality Improvement/Program Compliance
4. Resolving Consumer Complaints
5. Licensing
6. Sanctions
7. Other

b. Managed Care (Mental Health Managed Care
4.b.1
4.b.2

4.b.3
4.b.4
4.b.5

Does the State have a Medicaid Managed Care initiative?
Does the State Mental Health Agency have any responsibilities for mental health services
provided through Medicaid Managed Care?

If yes, please check the responsibilities the SMHA has:
Direct contractual responsibility and oversight of the MCOs or BHOs
Setting Standards for mental health services

4.b.6
4.b.7
4.b.8

Coordination with state health and Medicaid agencies
Resolving mental health consumer complaints
Input in contract development
Performance monitoring

4.b.9

Other

Are Data for
these programs
reported on URS
Tables?

Data Reporting: Please describe the extent to which your information systems allows the generation of unduplicated
client counts between different parts of your mental health system. Please respond in particular for Table MHBG 11a and
MHBG 11b, which require unduplicated counts of clients served across your entire mental health system.

121

Are the data reporting in the
tables?
5.a.

5.b.
5.c.
5.d.
5.e.

Unduplicated :counted once even if they were served in both State hospitals and community
programs and if they were served in community mental health agencies responsible for different
geographic or programmatic areas.
Duplicated: across state hospital and community programs
Duplicated: within community programs
Duplicated: Between Child and Adult Agencies
Plans for Unduplication: If you are not currently able to provide unduplicated client counts across all parts of
your mental health system, please describe your plans to get unduplicated client counts by the end of your Data
Infrastructure Grant.

Summary Administrative Data

6.a.

Report Year

6.b.

State Identifier
Summary Information on Data Submitted by SMHA:

6.c.

Year being reported: From:

6.d.

Person Responsible for Submission

6.e.

Contact Phone Number:

6.f.

Contact Address

6.g.

E-mail:

122

MHBG Table 11A (URS Table 2A). Profile of Persons Served, All Programs by Age, Gender, Race/Ethnicity
This table provides an aggregate profile of persons in the reporting year. The reporting year should be the latest state fiscal year for which data are
available. This profile is based on a client receiving services in programs provided or funded by the state mental health agency. The client profile takes
into account all institutional and community services for all such programs. Please provide unduplicated counts if possible.
Please report the data under the categories listed - "Total" are calculated automatically.
MHBG Table
11A.
Report Year:
State Identifier:
Total
Female

Male

Not
Availab
le

Total

American Indian or Alaska
Native
Female
Male
Not
Availabl
e

Asian
Female

Black or African American
Male

Not
Availabl
e

Female

Male

Not
Availabl
e

0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant Women
Are these numbers unduplicated?
Comments on Data (for Age):
Comments on Data (for
Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):

(continued on next page)

MHBG Table
11A.
Report Year:
State Identifier:

Native Hawaiian or Other
Pacific Islander
Female

Male

Not
Availabl
e

White

Hispanic * use only if data for

More Than One Race Reported

MHBG Table 11b are not
available.

Female

Male

Not
Availabl
e

Female

Male

Not
Availabl
e

Female

Male

Not
Availabl
e

Race Not
Available
Female

Male

0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant
Women

124

Not
Availabl
e

MHBG Table 11B (URS Table 2B). Profile of Persons Served, All Programs by Age, Gender and
Race/Ethnicity
Of the total persons served, please indicate the age, gender and the number of persons who are Hispanic/Latino or
not Hispanic/Latino. Total persons served would be the total as indicated in MHBG Table 11A.
Please report the data under the categories listed - "Total" are calculated automatically.
MHBG Table 11B.
Report Year:
State Identifier:
Not Hispanic or Latino
Female

Male

Not
Available

Hispanic or Latino
Female

Male

Not
Available

Hispanic or Latino Origin
Not Available
Female

Male

Not
Available

Total
Female

Male

Not
Available

Total

0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant Women
Comments on Data
(for Age):
Comments on Data
(for Gender):
Comments on Data
(for Ethnicity):
Comments on Data
(Overall):

125

MHBG Table 12 (URS Table 3). Profile of Persons served in tCommunity Mental Health Settings, State Psychiatric Hospitals and
OtherSettings
This table provides a profile for the clients that received public funded mental health services in community mental health
settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

MHBG Table
12
Report Year:
State
Identifier:
MHBG Table
12
Service Setting

Age 0-17
Female

Male

Age 18-20
Not
Available

Female

Male

Age 21-64
Not
Available

Female

Male

Age 65+
Not
Available

Female

Male

Not
Available

Community
Mental Health
Programs
State
Psychiatric
Hospitals
Other
Psychiatric
Inpatient
Residential
Treatment
Centers

(continued on next page)

126

MHBG Table 12 (cont.) Profile of Persons served in Community Mental Health Settings, State Psychiatric Hospitals and Other Settings
Table 12
Report Year:
State Identifier:
Age Not Available
Table 12
Service Setting

Female

Male

Total

Not Available

Female

Male

Not Available

Total

Community Mental Health Programs
State Psychiatric Hospitals
Other Psychiatric Inpatient
Residential Treatment Centers
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):
Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same
year and thus would be reported in counts for both rows.

Instructions:
1
2
3
4
5

States that have county psychiatric hospitals that serves as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.
If forensic hospitals are part of the state mental health agency system include them.
Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row
Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other Psychiatric
Inpatient" row. Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.
A person who is served in both community settings and inpatient settings should be included in both rows
RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned
programs of mental health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a
psychiatrist, psychologist, social worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified
by DSM-IV codes-other than the codes for mental retardation, developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with
a mental illness).”

127

Table 13A Profile of Persons with SMI/SED Served by Age, Gender and Race/Ethnicity
This table provides a profile for the clients that received public funded mental health services in community mental health
settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
MHBG Table
13A
Report Year:
State
Identifier:
MHBG Table
13A
Service Setting

Age 0-17
Female

Male

Age 18-20
Not Available

Female

Male

Age 21-64
Not Available

Female

Male

Not Available

Community
Mental Health
Programs
State
Psychiatric
Hospitals
Other
Psychiatric
Inpatient
Residential
Treatment
Centers

(continued on next page)

128

MHBG Table 13A (cont.) Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings
MHBG Table 13A
Report Year:
State Identifier:
Age 65+
MHBG Table 13A
Service Setting

Female

Male

Age Not Available
Not
Available

Female

Male

Not
Available

Total
Female

Male

Not
Available

Total

Community Mental Health
Programs
State Psychiatric Hospitals
Other Psychiatric Inpatient
Residential Treatment Centers
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):
Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same year and thus would be
reported in counts for both rows.

Instructions:
1

States that have county psychiatric hospitals that serve as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.

If forensic hospitals are part of the state mental health agency system include them.

Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row
Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other Psychiatric Inpatient" row.
Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.

4
5
6

A person who is served in both community settings and inpatient settings should be included in both rows
RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned programs of mental
health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a psychiatrist, psychologist, social
worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified by DSM-IV codes-other than the codes for
mental retardation, developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with a mental illness).”

129

MHBG Table 13B (URS Table 14A). Profile of Persons with SMI/SED served by Age,
Gender and Race/Ethnicity
This is a developmental table similar to MHBG Tables 11a and 11b (URS Table 2A. and 2B). This table requests counts for persons with SMI or SED using the
definitions provided by the CMHS. MHBG Table 11A and 11B (URS Table 2A. and 2B). included all clients served by publicly operated or funded programs. This
table counts only clients who meet the CMHS definition of SMI or SED. For many states, this table may be the same as MHBG Tables 11 A and 11B (URS Table
2A. and 2B). For 2013, states should report using the Federal Definitions of SMI and SED if they can report them, if not, please report using your state’s definitions
of SMI and SED and provide information below describing your state’s definition.
Please report the data under the categories listed - "Total" are calculated automatically.
MHBG Table
13B
Report Year:
State
Identifier:
Total
Female

Male

Not
Available

American Indian or
Alaska Native
Total

Female

Male

Not
Available

Asian
Female

Male

Black or African American
Not
Available

Female

Male

Not
Available

Native Hawaiian or Other
Pacific Islander
Female

Male

Not
Available

0-12 Years
13-17 years
18-20 years
21-64 years
65-74 years
75+ years
Not Available
Total
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):

(continued on next page)

130

(

MHBG Table
13B.
Report Year:
State
Identifier:
Hispanic *use only if data
for MHBG Table 13c are
not available

White
Female

Male

Not
Available

More Than One Race
Reported
Female

Male

Not
Available

Race Not Available
Female

Male

Not Available

0-12 Years
13-17 years
18-20 years
21-64 years
65-74 years
75+ years
Not Available
Total
1. State Definitions Match the Federal Definitions:
Yes
No

Adults with SMI, if No describe or attach state definition:

Yes

Children with SED, if No describe or attach state definition:

Yes

Diagnoses included in State SED definition:

Diagnoses included in state SMI definition:

131

MHBG Table 13C (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender
and Ethnicity
Of the total persons served, please indicate the age, gender and the number of persons who meet the Federal definition of SMI and SED and who are Hispanic/Latino or not
Hispanic/Latino. The total persons served who meet the Federal definition of SMI or SED should be the total as indicated in MHBG Table 13b.

Please report the data under the categories listed - "Total" are calculated automatically.
MHBG Table 13C
Report Year:
State Identifier:
Not Hispanic or Latino
Female

Male

Not
Available

Hispanic or Latino
Female

Male

Not
Available

Hispanic or Latino Origin
Not Available
Female

Male

Not
Available

Total
Female

Male

Not
Available

0 - 12 Years
13 - 17 years
18 - 20 years
21-64 years
65-74 years
75+ years
Not Available
Total
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for
Race/Ethnicity):
Comments on Data (Overall):

132

Total

MHBG Table 14 (URS Table 6): Profile of Client Turnover

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
MHBG Table 14.
Report Year:
State Identifier:

Profile of Service Utilization

Total Served at
Beginning of
Year
(unduplicated)

Admissions
During the
year
(duplicated)

Discharges
During the
year
(duplicated)

Length of Stay (in
Days): Discharged
Patients

For Clients in
Facility for Less
Than 1 Year:
Average Length of
Stay (in Days):
Residents at end of
year

Average
(Mean)

Median

For Clients in Facility More
Than 1 Year: Average
Length of Stay (in Days):
Residents at end of year
Average
(Mean)

Median

State Hospitals
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Other Psychiatric Inpatient
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Residential Tx Centers
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Community Programs
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Comments on Data (State Hospital):
Comments on Data (Other Inpatient):
Comments on Data (Residential
Treatment):
Comments on Data (Community
Programs):
Comments on Data (Overall):

133

E. Performance Data and Outcomes
•

•

•
•

•

•
•

MHBG Table 15 (URS Table 17). Profile of Adults with Serious Mental Illnesses Receiving
Specific Services During the Year. MHBG Table 15 provides the number of unduplicated
Adults with SMI receiving family psychoeducation, integrated treatment for co-occurring
disorders, illness self-management and medication management.
MHBG Table 16A (URS Table 4). Profile of Adult Clients By Employment Status. MHBG
Table 16A describes the status of adults clients served in the report year by the public mental
health system in terms of employment status. The focus is on employment for the working
age population, recognizing, however, that there are clients who are disabled, retired or who
homemakers, care-givers, are etc and not a part of the workforce. These persons should be
reported in the “Not in Labor Force” category. This category has two subcategories: retired
and other. (The totals of these two categories should equal the number in the row for “Not in
Labor Force”). Unemployed refers to persons who are looking for work but have not found
employment. Data should be reported for clients in non-institutional settings at time of
discharge or last evaluation.
MHBG Table 16B (URS Table 4A). Profile Of Adult Clients By Employment Status: By
Primary Diagnosis Reported. MHBG Table 16B request information on the status of adult
clients served in the report year by the public mental health system in terms of employment
status by primary diagnosis reported.
MHBG Table 17 (URS Table 15). Living Situation Profile. MHBG Table 17 requests
information regarding the number of Individuals in Each Living Situation as collected by the
most recent assessment in the reporting period. Specifically, information is collected on the
individual’s last known living situation. Living situations include, but are not limited to:
private residence, foster care, residential care, jail/correctional facility, homeless shelter and
other.
MHBG Table 18 (URS Table 19B). Profile of Change in School Attendance. MHBG Table
18 measures the change in days attended over time. Information requested includes
information on suspensions, expelled, and changes in the school attendance.
MHBG Table 19 (URS Table 9). Social Connectedness and Improved Functioning. MHBG
Table 19 requests states to provide information for youth and adults regarding Social
Connectedness. In addition, States are requested to provide information on functional
domains that provide a general sense of an individual’s ability to develop and maintain
relationships, cope with challenges and a sense of community belonging.
MHBG Table 20A (URS Table 11). Summary Profile of Client Evaluation of Care. MHBG
Table 20A requests information that evaluates the “experience” of care for individuals that
participate in the public mental health system. Specifically, the evaluation focuses on several
areas including: access, quality and the appropriateness of services, participation in treatment
planning and general satisfaction with services. Please provide unduplicated counts, if
possible. This table provides an aggregate profile of persons served in the reporting year.
The reporting year should be the latest state fiscal year for which data are available. This
profile is based on a client's last known Living Situation.
MHBG Table 20B (URS Table 11A). Consumer Evaluation of Care By Consumer
Characteristics: Race/Ethnicity.
MHBG Table 21 (URS Table 19A). Profile Of Criminal Justice Or Juvenile Justice
Involvement. MHBG Table 21 requests information to measure the change in Arrests over
time.

•

MHBG Table 22 (URS Table 16). Profile of Adults With Serious Mental Illnesses And
Children With Serious Emotional Disturbances Receiving Specific Services. MHBG Table 22
requests information regarding the number and demographics of individuals that are
receiving specific evidenced-based services. In addition, the table requests information on if
and how states monitor the fidelity for the evidenced based services.
MHBG Table 23A (URS Table 20A). Profile of Non-Forensic (Voluntary and CivilInvoluntary) Patients Readmission to Any State Psychiatric Inpatient Hospital Within 30/180
Days of Discharge. MHBG Table 23A provides the total number of discharges within the
year, the number of readmissions within 30-days and 180-days and the percent readmitted by
age, gender, race, and ethnicity.
MHBG Table 23B (URS Table 20B). Profile of Forensic Patients Readmission to Any State
Psychiatric Inpatient Hospital Within 30/180 Days of Discharge. MHBG Table 23B
provides the total number of discharges within the year, the number of readmissions within
30-days and 180-days and the percent readmitted by age, gender, race, and ethnicity.
MHBG Table 24 (URS Table 21). Profile of Non-Forensic (Voluntary and Civil-Involuntary
Patients) Readmission to Any Psychiatric Inpatient Care Unit (State Operated or Other
Psychiatric Inpatient Unit) within 30/180 Days of Discharge This table provides the total
number of discharges from inpatient care units w/I the year, the number of readmissions w/I
30-days and 180-days and the percent readmitted by age, gender, race, and ethnicity.

135

MHBG Table 15 (URS Table 17): Profile of Adults with Serious Mental Illnesses Receiving Specific Services
During The Year:

MHBG Table 15
Report Year:
State Identifier:
ADULTS WITH SERIOUS MENTAL
ILLNESS
Receiving Family
Psychoeducation

Receiving Integrated
Treatment for Co-occurring
Disorders (MH/SA)

Receiving
Illness Self
Management

Receiving Medication
Management

Age

18-20
21-64
65-74
75+
Not Available
TOTAL
Gender
Female
Male
Not Available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Unknown
Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic origin not available

Do You monitor fidelity
for this service?

Yes

IF YES,
What fidelity measure do you use?
Who measures fidelity?
How often is fidelity measured?
Is the SAMHSA EBP Toolkit used to guide EBP Implementation?
Have staff been specifically trained to implement the EBP?

136

* Hispanic is part of the total served.
Comments on Data (overall):
Comments on Data (Family Psychoeducation):
Comments on Data (Integrated Treatment for Co-occurring Disorders):
Comments on Data (Illness Self Management):
Comments on Data (Medication Management):

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

137

MHBG Table 16A (URS Table 4) Profile of Adult Clients by
Employment Status
This table describes the status of adults clients served in the report year by the public mental health system in terms of employment status. The focus is on employment for the working age
population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, care-givers, etc and not a part of the workforce. These persons should be reported in
the “Not in Labor Force” category. This category has two subcategories: retired and other. (The totals of these two categories should equal the number in the row for “Not in Labor Force”).
Unemployed refers to persons who are looking for work but have not found employment. Data should be reported for clients in non-institutional settings at time of discharge or last
evaluation.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
MHBG Table 16 A
Report Year:
State Identifier:
18-20
Adults Served
Employed:
Competitively
Employed Full or
Part Time (includes
Supported
Employment)

Female

Male

21-64
Not
Available

Unemployed
Not In Labor Force:
Retired, Sheltered
Employment,
Sheltered
Workshops, Other
(homemaker,
student, volunteer,
disabled, etc.)
Not Available
Total
How Often Does your State Measure Employment Status?
What populations are included:
Comments on Data (for
Age):
Comments on Data (for
Gender):
Comments on Data
(Overall):

Female

Male

65+
Not
Available

Female

Male

Not
Available

Age Not Available
Not
Female Male Available

Total
Female

Male

Not
Available

Total

MHBG Table 16B (URS Table 4A) Optional Profile of Adult Clients by Employment Status: by Primary
Diagnosis Reported
The workgroup exploring employment found that the primary diagnosis of consumers results in major differences in employment status. The workgroup has
recommended that we explore the ability of states to report employment by primary diagnosis and the impact of diagnosis on employment. The workgroup
recommended 5 diagnostic clusters for reporting.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR
CELLS!
MHBG Table 10020
Report Year:
State Identifier:

Clients
Primary Diagnosis

Schizophrenia & Related Disorders
(295)
Bipolar and Mood Disorders (296, 300.4,
301.11, 301.13, 311)
Other Psychoses (297, 298)
All Other Diagnoses
No Dx and Deferred DX (799.9, V71.09)
Diagnosis Total

Comments on Data (for Diagnosis):

Employed:
Competitively Employed
Full or Part Time
(includes Supported
Employment)

Unemployed

Not In Labor Force:
Retired, Sheltered
Employment, Sheltered
Workshops, Other
(homemaker, student,
volunteer, disabled,
etc.)

Employment Status
Not Available

Total

MHBG Table 17 (URS Table 15).
Living Situation Profile:
Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period
All Mental Health Programs by Age, Gender, and Race/Ethnicity
Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal
year for which data are available. This profile is based on a client's last known Living Situation.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 18
Report Year:
State Identifier:
Private
Residence

Foster
Home

Residential
Care

Crisis
Residence

Children's
Residential
Treatment

Institutional
Setting

Jail/
Correctional
Facility

Homeless/
Shelter

Other

0-17
18-64
65 +
Not Available
TOTAL
Female
Male
Not Available
TOTAL
American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White/Caucasian
Hispanic *
More than One Race Reported
Race/Ethnicity Not Available
TOTAL

(continued on next page)

Total

MHBG Table 17 (cont.) Living
Situation Profile:
Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period
All Mental Health Programs by Age, Gender, and Race/Ethnicity
Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal
year for which data are available. This profile is based on a client's last known Living Situation.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Please report the data under the Living Situation categories listed - "Total" are calculated automatically.
MHBG Table 17
Report Year:
State Identifier:

Private
Residence

Foster
Home

Residential
Care

Crisis
Residence

Hispanic or Latino Origin
Non Hispanic or Latino Origin
Hispanic or Latino Origin Not Available
TOTAL
Comments on Data:
How Often Does your State Measure Living
Situation?
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available

Children's
Residential
Treatment

Institutional
Setting

Jail/
Correctional
Facility

Homeless/
Shelter

Other

Total

Table 18 (URS Table 19b) Profile of Change in School Attendance

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
1. This is a developmental measure. To assist in the development process, we are asking states to report information on the school attendance outcomes of mental health consumers with their December 2007 MHBG submission.
2. The SAMHSA National Outcome Measure for School Attendance measures the change in days attended over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3
Consumer Self-Report items on School Attendance, you may report them here.
3. If your SMHA has data on School Attendance from alternatives sources, you may also report that here. If you only have data for School attendance for consumers in this year, please report that in the T2 columns. If you can calculate the change in Attendance from T1 to T2, please use all these columns.
4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.
5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether treatment data are collected).

Table 19b. Profile of Change in School Attendance
State:

Time period in which services were received:

For Consumers in Service for at least 12 months

"T1" Prior 12 months
(more than 1 year ago)

"T2" Most Recent 12 months
(this year)

T1 to T2 Change

# Not
# Not
# Suspended Suspended or
No
# Suspended Suspended or
or Expelled
Expelled
Expelled
Response or Expelled

Total

If Suspended at T1 (Prior 12 Months)

No
Response

Impact of Services

If Not Suspended at T1 (Prior 12 Months)

# with an
# with No
# with an
# with No
Expelled or
Suspension
Expelled or Suspension
Suspended in or Expulsion
Suspended in or Expulsion
T2
at T2
No Response
T2
at T2

No
Response

Over the last 12 months, the number of days my child was in school have

# Greater # Stayed
(Improved) the Same

# Fewer days
(gotten
# Not
worse)
Applicable

No
response

Total
Responses
0

Gender
Male

Female

Gender NA

Age
Under 18

For Consumers Who Began Mental Health Services during the past 12 month

"T1" 12 months prior to beginning
services

"T2" Since Beginning Services
(this year)

T1 to T2 Change

# Not
# Not
# Suspended Suspended or
No
# Suspended Suspended or
or Expelled
Expelled
Response or Expelled
Expelled

Total

No
Response

Impact of Services

If Not Suspended at T1
(Prior 12 Months)

If Suspended at T1 (Prior 12 Months)

# with an
# with No
# with an
# with No
Expelled or
Suspension
Expelled or Suspension
Suspended in or Expulsion
Suspended in or Expulsion
T2
at T2
T2
at T2
No Response

Since starting to receive MH Services, the number of days my child was in
school have

No
Response
0

# Greater # Stayed
(Improved) the Same

# Fewer days
(gotten
# Not
Applicable
worse)

No
response

Total
Responses
0

Gender
Male

Female

Gender NA

Age
Under 18

See Page 2 for additional Questions about the source of this data.
Source of School Attendance Information

Measure of School Attendance

Mental health programs include:
Region for which data are reported:

1) Consumer survey (recommended items)

2) Other Survey: Please send us items

3) Mental health MIS

4) State Education Department

5) Local Schools/Education Agencies

6) Other (specify)

1) School Attendance

1) Children with SED only
1) The whole state

2) Other: (Specify)

2) Other Children (specify)

3) Both.

2) Less than the whole state (please describe)

What is the Total Number of Persons Surveyed or for whom School Attendance Data Are Reported
Child/Adolescents
1. If data is from a survey, What is the total Number of people from which the sample was drawn?
2. What was your sample size? (How many individuals were selected for the sample)?
3. How many survey Contacts were made? (surveys to valid phone numbers or addresses)
4. How many surveys were completed? (survey forms returned or calls completed) If data source was not
a Survey, How many persons were data available for?
5. What was your response rate? (number of Completed surveys divided by number of Contacts):

MHBG Table 19 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS
AND/OR CELLS!
MHBG Table 19: NOMS Social Connectedness & Functioning
Report Year (Year Survey was Conducted):
State Identifier:
Adult Consumer Survey Results:

Number of Positive
Responses

Responses

Percent Positive
(calculated)

Number of Positive
Responses

Responses

Percent Positive
(calculated)

1. Social Connectedness
2. Functioning
Child/Adolescent Consumer Survey Results:

3. Social Connectedness
4. Functioning
Comments on Data:

Adult Social Connectedness and Functioning Measures

1. Did you use the recommended new Social Connectedness Questions? Yes No

Measure used

2: Did you use the recommended new Functioning Domain Questions? Yes No

Measure used

3. Did you collect these as part of your MHSIP Adult Consumer Survey? Yes No
If No, what source did you use?
Child/Family Social Connectedness and Functioning Measures

4: Did you use the recommended new Social Connectedness Questions? Yes No
5: Did you use the recommended new Functioning Domain Questions? Yes No
6. Did you collect these as part of your YSS-F Survey? Yes No
If No, what source did you use?

Measure used
Measure used

Recommended Scoring Rules
Please use the same rules for reporting Social connectedness and Functioning Domain scores as for calculating
other Consumer Survey Domain scores for Table MHBG Table
20a: E.g.:
1. Recode ratings of “not applicable” as missing values.
2. Exclude respondents with more than 1/3rd of the items in that domain missing.
3. Calculate the mean of the items for each respondent.
4. FOR ADULTS: calculate the percent of scores less than 2.5. (percent agree and strongly agree).
5. FOR YSS-F: calculate the percent of scores greater than 3.5. (percent agree and strongly agree).

144

Items to Score in the Functioning Domain:
Adult MHSIP Functioning Domain:
1 I do things that are more meaningful to me.
2 I am better able to take care of my needs.
3 I am better able to handle things when they go wrong.
4 I am better able to do things that I want to do.
5 My Symptoms are not bothering me as much (this question already is part of the MHSIP Adult Survey)
YSS-F Functioning Domain Items:
1 My child is better able to do things he or she wants to do.
2 My child is better at handling daily life. (existing YSS-F Survey item)
3 My child gets along better with family members. (existing YSS-F Survey item)
4 My child gets along better with friends and other people. (existing YSS-F Survey item)
5 My child is doing better in school and/or work. (existing YSS-F Survey item)
6 My child is better able to cope when things go wrong. (existing YSS-F Survey item)

Items to Score in the Social Connectedness Domain:
Adult MHSIP Social Connectedness Domain:
1 I am happy with the friendships I have.
2 I have people with whom I can do enjoyable things.
3 I feel I belong in my community.
4 In a crisis, I would have the support I need from family or friends.
YSS-F Social Connectedness Domain Items:
1 I know people who will listen and understand me when I need to talk
2 I have people that I am comfortable talking with about my child's problems.
3 In a crisis, I would have the support I need from family or friends.
4 I have people with whom I can do enjoyable things

MHBG Table 20A (URS Table 11): Summary Profile of Client
Evaluation of Care

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR
CELLS!
MHBG Table 20A
Report Year (Year Survey was Conducted):
State Identifier:
Number of
Positive
Responses

Adult Consumer Survey Results:

Responses

Confidence Interval*

Responses

Confidence Interval*

1. Reporting Positively About Access.
2. Reporting Positively About Quality and Appropriateness for Adults
3. Reporting Positively About Outcomes.
4. Adults Reporting on Participation In Treatment Planning.
5. Adults Positively about General Satisfaction with Services.
Child/Adolescent Consumer Survey Results:

Number of
Positive
Responses

1. Reporting Positively About Access.
2. Reporting Positively about General Satisfaction for Children.
3. Reporting Positively about Outcomes for Children.
4. Family Members Reporting on Participation In Treatment Planning for their Children
5. Family Members Reporting High Cultural Sensitivity of Staff.
Please enter the number of persons responding positively to the questions and the number of total responses
within each group. Percent positive will be calculated from these data.
* Please report Confidence Intervals at the 95% level. See directions below regarding the calculation of confidence intervals.

Comments on Data:

Adult Consumer Surveys
1. Was the Official 28 Item MHSIP Adult Outpatient Consumer Survey Used?

1.a.
1.
2.
3.
4.
1.b.
1.c.

If no, which version:
Original 40 Item Version
21-Item Version
State Variation of MHSIP
Other Consumer Survey
If other, please attach instrument used.
Did you use any translations of the MHSIP into another language?
2. Other Language:

Adult Survey Approach:
2. Populations covered in survey? (Note all surveys should cover all regions of state)

146

2.a. If a sample was used, what sample methodology was used?

4. Other Sample:

Adult Consumer Surveys (Continued)

2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?

3. Please Describe the populations included in your sample: (e.g., all adults, only adults with SMI, etc.)

3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):

4. Methodology of collecting data? (Check all that apply)
Self-Administered

Interview

Phone
Mail
Face-to-face
Web-Based
4.b. Who administered the Survey? (Check all that apply)

6. Other: describe:

5. Are Responses Anonymous, Confidential and/or Linked to other Patient Databases?

6. Sample Size and Response Rate
6a. How many Surveys were Attempted (sent out or calls initiated)?
6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)
6.c How many surveys were completed? (survey forms returned or calls completed)
6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)
6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count these survey's as "completed"
for the calculation of response rates?

7. Who Conducted the Survey
7.a. SMHA Conducted or contracted for the Survey (survey done at state level)
7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey
(survey was done at the local or regional level)
7.c. Other: Describe:
* Report Confidence Intervals at the 95% confidence level

147

Note: The confidence interval is the plus-or-minus figure usually reported in newspaper or television opinion poll results. For example, if you
use a confidence interval of 4 and 47% percent of your sample picks an answer you can be "sure" that if you had asked the question of the
entire relevant population between 43% (47-4) and 51% (47+4) would have picked that answer.
The confidence level tells you how sure you can be. It is expressed as a percentage and represents how often the true percentage of the
population who would pick an answer lies within the confidence interval. The 95% confidence level means you can be 95% certain; the 99%
confidence level means you can be 99% certain. Most researchers use the 95% confidence level.
When you put the confidence level and the confidence interval together, you can say that you are 95% sure that the true percentage of the
population is between 43% and 51%. (From www.surveysystem.com)

Child/Family Consumer Surveys
1. Was the MHSIP Children/Family Survey (YSS-F) Used?
If No, what survey did you use?
If no, please attach instrument used.

1.c. Did you use any translations of the Child MHSIP into another language?
2. Other Language:

Child Survey Approach:
2. Populations covered in survey? (Note all surveys should cover all regions of state)
2.a. If a sample was used, what sample methodology was used?

4. Other Sample:

2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?

2a. If yes to 2, please describe how your survey persons no longer receiving services.

3. Please Describe the populations included in your sample: (e.g., all children, only children with SED, etc.)

3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):

4. Methodology of collecting data? (Check all that apply)
Self-Administered

Interview

Phone
Mail
Face-to-face
Web-based
4.b. Who administered the Survey? (Check all that apply)

6. Other: describe:

148

5. Are Responses Anonymous, Confidential and/or Linked to other Patient Databases?

6. Sample Size and Response Rate
6a. How many Surveys were Attempted (sent out or calls initiated)?
6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)
6.c How many surveys were completed? (survey forms returned or calls completed)
6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)
6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count
these survey's as "completed" for the calculation of response rates?

149

MHBG Table 20b (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: (Optional Table by Race/Ethnicity.)

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 20b.
Report Year:
State Identifier:

Adult Consumer Survey Results:
*State used the 2 question version for
Hispanic Origin

Indicators
Adult Consumer
Survey Results:
1. Reporting Positively
About Access.

Total

# Positive

Responses

American Indian or
Alaska Native

# Positive

Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about
Hispanic Origin/Status

Yes

Responses

Asian

# Positive

Responses

Black or African American

# Positive

Responses

Native Hawaiian or Other
Pacific Islander

# Positive

Responses

White

# Positive

Responses

More than One Race
Reported

# Positive

Responses

Other/ Not Available

# Positive

Responses

Hispanic Origin*

# Positive

Responses

2. Reporting Positively
About Quality and
Appropriateness.
3. Reporting Positively
About Outcomes.
4. Reporting Positively
about Participation in
Treatment Planning
5. Reporting Positively
about General
Satisfaction
6. Social Connectedness
7. Functioning

Child/Adolescent Family Survey Results:
*State used the 2 question version for
Hispanic Origin

Indicators
Child/Adolescent
Family Survey Results:

Total

# Positive

Responses

Yes

American Indian or
Alaska Native

# Positive

Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about
Hispanic Origin/Status

Responses

Asian

# Positive

Responses

Black or African American

# Positive

Responses

Native Hawaiian or Other
Pacific Islander

# Positive

Responses

White

# Positive

Responses

More than One Race
Reported

# Positive

Responses

Other/ Not Available

# Positive

Reporting Positively
About Access.
Reporting Positively
About General
Satisfaction
Reporting Positively
About Outcomes.
Reporting Positively
Participation in Treatment
Planning for their
Children.
Reporting Positively
About Cultural Sensitivity
of Staff.
6. Social Connectedness
7. Functioning

Comments on Data:

Please enter the number of persons responding positively to the questions and the number of total responses within each group. Percent positive will be calculated from these data.

Responses

Hispanic Origin*

# Positive

Responses

MHBG Table 21 (URS Table 19a) Profile of Criminal Justice or Juvenile Justice Involvement:

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
1. This is a developmental measure. To assist in the development process, we are asking states to report information on the arrest histories of mental health consumers with their December 2007 MHBG submission.
2. The SAMHSA National Outcome Measure for Criminal Justice measures the change in Arrests over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If
your state has used the 3 Consumer self-report items on criminal justice, you may report them here.
3. If your SMHA has data on Arrest records from alternatives sources, you may also report that here. If you only have data for arrests for consumers in this year, please report that in the T2 columns. If you can calculate the change
in Arrests from T1 to T2, please use all those columns.
4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.
5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether
treatment data are collected).

State:

Time period in which services were received:

For Consumers in Service for at least 12 months
T1

"T1" Prior 12 months
(more than 1 year ago)

"T2" Most Recent 12 months
(this year)

Not
Arrested

Arrested

No
Response

T1 to T2 Change

Not
Arrested

Arrested

If Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

Assessment of the Impact of Services

If Not Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

Over the last 12 months, my encounters with the police have…
# Reduced
(fewer
# Stayed
#
encounters) the Same Increased

No
Response

# Not
Applicable

No
Response

Total
Responses

Total

Total Children/Youth (under age 18)

Male

Female
Gender NA
Total Adults (age 18 and over)
Male
Female
Gender NA

0
0
0

0
0
0
0

For Consumers Who Began Mental Health Services during the past 12 months
T1

"T1" 12 months prior to beginning
services

"T2" Since Beginning Services
(this year)

Not
Arrested

Arrested

Total
Total Children/Youth (under age 18)
Male
Female
Gender NA
Total Adults (age 18 and over)
Male
Female
Gender NA

No
Response

T1 to T2 Change

Not
Arrested

Arrested

If Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

Assessment of the Impact of Services

If Not Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

Since starting to receive MH Services, my encounters with the police have…
# Reduced
(fewer
# Stayed
#
encounters) the Same Increased

No
Response

# Not
Applicable

No
Response

Total
Responses

0
0
0
0

151

152

Table 22: Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving
Specific Services:

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 22.

Report Year:
State Identifier:
Adults with Serious Mental Illnes s (SMI)

Children with Serious Em otional Dis turbance (SED)

Total
N
N Receiving
unduplicated N Receiving
N Receiving
Receiving
As s ertive
N - Adults
Supported
Therapeutic
Supported
Com m unity
with SMI
Em ploym ent
Fos ter Care
Hous ing
Treatm ent
s erved

N Receiving
MultiSys tem ic
Therapy

N Receiving
Fam ily
Functional
Therapy

Total
unduplicated
N - Children
with SED

Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available

TOTAL

Gender
Fem ale
Male
Not Available

Race/Ethnicity
Am erican Indian/Alas ka Native
As ian
Black/African Am erican
Hawaiian/Pacific Is lander
White
His panic*
More than one race
Not Available

Hispanic/Latino Origin
His panic/Latino Origin
Non His panic/Latino
Not Available

Do You monitor fidelity
for this service?

Yes / No

IF YES,
What f idelity measure do you use?
Who measures f idelity?
How of ten is f idelity measured?
Is the SAMHSA EBP Toolkit used to
guide EBP Implementation?
Have staf f been specif ically trained
to implement the EBP?

* Hispanic is part of the total served.

Yes

Comments on Data (overall):
Comments on Data (Supported
Housing):
Comments on Data (Supported
Employment):
Comments on Data (Assertive
Community Treatment):
Comments on Data (Therapeutic
Foster Care):
Comments on Data (Multi-Systemic
Therapy):
Comments on Data (Family
Functional Therapy):
* Hispanic: Only use the "Hispanic" row under Race if data f or Hispanic as a Ethnic Origin are not available

MHBG Table 23A (URS Table 20A). Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients
Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge

MHBG Table 23A.

Report Year:
State Identifier:
Total number of
Discharges in
Year

Number of Readmissions to
ANY STATE Hospital within

30 days

TOTAL

180 days

Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available
Gender
Female
Male
Gender Not Available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Race Not Available
Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic/Latino Origin Not Available
Are Forensic Patients Included?
Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

Percent Readmitted

30 days

180 days

MHBG Table 23B (URS Table 20B). Profile of Forensic Patients Readmission to Any State Psychiatric
Inpatient Hospital Within 30/180 Days of Discharge

MHBG Table 23B.

Report Year:
State Identifier:
Total number
of Discharges
in Year

Number of Readmissions to
ANY STATE Hospital within

30 days

TOTAL

180 days

Percent Readmitted

30 days

180 days

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

155

MHBG Table 24 (URS Table 21). Profile of Non-Forensic (Voluntary and Civil-Involuntary Patients)
Readmission to Any Psychiatric Inpatient Care Unit (State Operated or Other Psychiatric Inpatient Unit)
Within 30/180 Days of Discharge
MHBG Table 24.

Report Year:
State Identifier:
Total number
of Discharges
in Year

Number of Readmissions to ANY
Psychiatric Inpatient Care Unit
Hospital within
30 days

TOTAL

Percent Readmitted

180 days

30 days

180 days

1. Does this table include readmission from state psychiatric hospitals?
2. Are Forensic Patients Included?
Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

156

Block Grant Reporting Section
FY 2014

CFDA 93.959 (Substance Abuse Prevention and
Treatment)

U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration

157

Table of Contents

A. Introduction
B. Annual Update
MHBG Table 1 Priority Area and Annual Performance Indicators – Progress Report
C. State Agency Expenditure Reports
SABG Table 2 - State Agency Expenditure Report
SABG Table 3 – SABG Expenditures by Service.
SABG Table 4 - State Agency SABG Expenditure Compliance Report
SABG Table 5a- SABG Primary Prevention Expenditures Checklist
SABG Table 5b-SABG Primary Prevention Expenditures by IOM Category
SABG Table 5c – SABG Primary Prevention Targeted Priorities
SABG Table 6 – SABG Resource Development Expenditure Checklist
SABG Table 7 – SABG Statewide Entity Inventory.
SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse
Prevention and Treatment
SABG Table 8b - Base and Maintenance of Effort for Statewide Non-Federal Expenditures
for Tuberculosis to Individuals in Substance Use Disorder Treatment,
SABG Table 8c - Base and Maintenance of Effort for Statewide Non-Federal Expenditures
for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment
SABG Table 8d - Base and Maintenance of Effort for Expenditures for Services to Pregnant
Women and Women with Dependent Children
D. Population and Services Reports
SABG Table 9 - Prevention Strategy Report
SABG Table 10 - Treatment Utilization Matrix
SABG Table 11 - Number of Persons Served (Unduplicated Count) for Alcohol and Other
Drug Use
SABG Table 12 – SABG HIV Designated States Early Intervention Services
SABG Table 13 - Charitable Choice

E. Performance Data and Outcomes
Treatment Performance Measures
SABG Table 14. - Employment/Education Status.
SABG Table 15 - Stability of Housing.
SABG Table 16 - Criminal Justice Involvement.
SABG Table 17 – Change in Abstinence–Alcohol Use.
SABG Table 18 - Change in Abstinence – Other Drug Use.
SABG Table 19 – Change in Social Support of Recovery.
SABG Table 20 - Retention. This table collects information regarding retention.
Prevention Performance Measures
SABG Table 21 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: 30
Day Use. This table collects information on abstinence from drug use/alcohol use.

158

SABG Table 22 - 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.
SABG Table 23 - 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.
SABG Table 24 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure:
Perception of Disapproval/Attitudes.
SABG Table 25 - Employment/Education; Measure: Perception of Workplace Policy.
SABG Table 26 - Employment/Education; Measure: Average Daily School Attendance Rate.
SABG Table 27 - Crime and Criminal Justice; Measure: Alcohol-Related Traffic Fatalities.
SABG Table 28 - Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests.
SABG Table 29 - Social Connectedness; Measure: Family Communications Around Drug
and Alcohol Use.
SABG Table 30 - Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or
Listening to a Prevention Message.
SABG Table 31 - Individual-Based Programs and Strategies; Measure: Number of Persons
Served By Age, Gender, Race, and Ethnicity.
SABG Table 32 - Population-Based Programs And Strategies; Measure: Number of Persons
Served By Age, Gender, Race, And Ethnicity.
SABG Table 33 - Number of Persons Served by Type of Intervention.
SABG Table 34 - Number of Evidence-Based Programs by Types of Intervention.
SABG Table 35 - Number of Evidence-based Programs and Strategies, and Total SA Block
Grant Funds Spent on Evidence-Based Programs/ Strategies.
Prevention Attachments A, B and C.
SABG Table 36 - (Optional Worksheet) Program/Strategy Detail for Computing the Total
Number of Evidence-based Programs and Strategies, and for Reporting Total SA Block
Grant Funds Spent on Substance Abuse Prevention Evidence-Based Programs and Strategies.

159

Section 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 an Annual Report that includes
expenditure summaries for the last completed State fiscal year (SFY) and the Substance Abuse
Prevention and Treatment Block Grant (SABG) award subject to CSAT compliance review
(Compliance Award) in the format provided in this guidance. The Annual Report will address the
purposes for which the SABG funds were expended, the recipients of grant funds, and the authorized
activities funded 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 Annual Reports
utilizing SAMHSA’s Web Block Grant Application System (BGAS). Annual Reports must be
received by SAMHSA not later than December 1 in order for State or Jurisdiction to receive its next
SAPT Block grant award. 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:
Plan and Repor t Due Dates
Planning Per iod

Application for
Feder al fiscal year

Plan Due Date

2014
2015
2016
2017

04/01/2013

07/01/2013 -06/30/2015

04/01/2015

07/01/2015 – 06/30/2017

Repor t Due Date

12/01/2013
12/01/2014
12/01/2015
12/01/2016

Compliance
with Feder al
fiscal year
awar d
FY 2011
FY 2012
FY 2013
FY 2014

States/Territories are required to prepare and submit an Annual report comprised of the following
sections:
Section B: Annual Update - 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 plan covering the last completed State fiscal year.
The report should also include a brief review of areas that the State and Jurisdiction identified in that
Block Grant plan 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 Reports - In this section, States should provide information
regarding expenditures for authorized activities and services for substance abuse prevention and
substance abuse treatment. States should provide a description of SABG 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 SABG expenditures for early
intervention services for HIV. In addition, States and Jurisdictions should identify the SABG
expenditures made available to intermediaries, administrative service organizations, and communityand faith-based organizations who received amounts from the SABG to provide authorized activities
to prevent and treat substance abuse.
160

Section D: Populations and Services Reports - In this section, States and Jurisdictions must provide
specific information regarding the number of individuals that were served with SABG 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.

161

B. Annual Update
The information States entered into the performance indicator tables (SABG Table 1) in the planning
section of the 2014/2015 Substance Abuse Treatment and Plan will automatically populate cells 1 – 6
in the progress report tables below. States are required to indicate whether each first-year
performance target/outcome measurement identified in the 2014/2015 Plan was “Achieved” or “Not
Achieved” in Cell 7, Report of Progress toward goal attainment. If a target was not achieved, a
detailed explanation must be provided as well as the remedial steps proposed to meet the target.
SABG Table 1 Priority Area and Annual Performance Indicators – Progress Report
2. Priority Type (SAP, SAT, MHP, MHS):
1. Priority Area:
3. Population(s) (SMI, SED, PWWDC, IVDUs, HIV EIS, TB, OTHER):
4. Goal of the priority area:

5. Strategies to attain the goal:
6. Annual Performance Indicators to measure goal success:
Indicator #1:
g)

Baseline measurement (Initial data collected prior to the first-year target/outcome):

h) First-year target/outcome measurement (Progress – end of SFY 2014):
i)

Second-year target/outcome measurement (Final – end of SFY 2015):

Data source:

k) Description of data:
l)

Data issues/caveats that affect outcome measures:

7. Report of Progress toward goal attainment:
First-year target:

____ Achieved

_____ Not Achieved (If not achieved, explain why.)

Reason why target was not achieved, and changes proposed to meet target:

162

C. State Agency Expenditure Reports
Substance Abuse Prevention and Treatment Block Grant Spending Reports
States and Jurisdictions are requested to provide information regarding SA Block Grant and State
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.
Please complete the tables described below:
•

SABG Table 2 - State Agency Expenditure Report. This table provides a report of SABG
expenditures during the last completed State fiscal year 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)).

•

SABG Table 3 – SABG Expenditures by Service. This table provides a report of SA Block
Grant expenditures by unduplicated individual and specific services during the last completed
State fiscal year. All Block grant-funded services regardless of award year should be included
in this report.
SABG Table 4 - State Agency SABG Expenditure Compliance Report. This table provides a
report of expenditures from the SA Block Grant Compliance Award for authorized activities
to prevent and treat substance abuse.
SABG Table 5a- SABG Primary Prevention Expenditures Checklist. This table provides a
report of prevention expenditures from the SAPT Block Grant Compliance Award for
primary prevention services.
SABG Table 5b- SABG Primary Prevention Expenditures by IOM Category. This table
provides a report of prevention expenditures by Institute of Medicine (IOM) categories from
the SAPT Block Grant Compliance Award for primary prevention services.
SABG Table 5c - SABG Primary Prevention Targeted Priorities. This table provides a
report of actual State primary prevention priorities and special population categories on
which the State expended primary prevention dollars from the SAPT Block Grant
Compliance Award.
SABG Table 6 - SABG Resource Development Expenditure Checklist. This table provides a
report of expenditures from the SAPT Block Grant Compliance Award for resource
development activities and/or services that are funded and/or or conducted by the State
Substance Abuse Authority.
SABG Table 7 – SABG Statewide Entity Inventory. This table provides a report of the
recipients of SA 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.
SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse
Prevention and Treatment. This table provides a report of aggregate State expenditures by the
State Substance Abuse Authority for authorized activities to prevent and treat substance
abuse during the last completed State fiscal year.
SABG Table 8b - Base and Maintenance of Effort for Statewide Non-Federal Expenditures
for Tuberculosis to Individuals in Substance Use Disorder Treatment, . This table provides a
report of Statewide expenditures of non-Federal funds expended for tuberculosis (TB)

•
•
•
•

•

163

•

services made available to individuals in substance user disorder (SUD) treatment during the
last completed State fiscal year
SABG Table 8c - Base and Maintenance of Effort for State-wide Non-Federal Expenditures
for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment.
This table provides a report of Statewide expenditures 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 the
last completed State fiscal year
SABG Table 8d - Base and Maintenance of Effort for Expenditures for Services to Pregnant
Women and Women with Dependent Children. This table provides a report of SA Block
Grant and/or State expenditures for services designed to address the treatment and recovery
support needs of substance using pregnant women and women with dependent children
during the last completed State fiscal year.

164

SABG Table 2 - State Agency Expenditure Report. This table provides a description of SAPT Block Grant expenditures for authorized activities to
prevent and treat substance abuse.
SABG Table 2

State Agency Expenditure Report

State Identifier:
Report Period- From:

To:
(Include ONLY funds expended by the executive branch agency administering the Substance Abuse Block Grant
Source of Funds

ACTIVITY
(See instr uctions for using Row 1.)

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

Substance Abuse Pr evention* and
Tr eatment
a.

Pr egnant Women and Women with
Dependent Childr en

All Other

Pr imar y Pr evention

Tuber culosis Ser vices

HIV Ear ly Inter vention Ser vices

State Hospital

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. Total

* Prevention other than primary prevention.

SABG Table 3 - SA Block Grant Expenditures by Service
165

SABG Table 3

SABG Expenditures by Service

State Identifier:
Report Period- From:

To:
Service

No. of Unduplicated Individuals

Unit Type

Unit Quantity

SABG Expenditures

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 examples of approaches include:
a.

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
b. Substance Abuse Primary Prevention
Classroom and/or small group sessions (Education)
Media campaigns (Information Dissemination)
Systematic Planning/Coalition and Community Team Building(Community Based
Process)
Parenting and family management (Education)
Education programs for youth groups (Education)
Community Service Activities (Alternatives)
Student Assistance Programs (Problem Identification and Referral)
Employee Assistance programs (Problem Identification and Referral)
Community Team Building (Community Based Process)
Promoting the establishment or review of alcohol, tobacco, and drug use policies
(Environmental)

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

166

SABG Table 3

SABG Expenditures by Service

State Identifier:
Report Period- From:

To:
Service

No. of Unduplicated Individuals

Unit Type

Unit Quantity

SABG Expenditures

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
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)

167

SABG Table 3

SABG Expenditures by Service

State Identifier:
Report Period- From:

To:
Service

No. of Unduplicated Individuals

Unit Type

Unit Quantity

SABG Expenditures

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
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

168

SABG Table 3

SABG Expenditures by Service

State Identifier:
Report Period- From:

To:
Service

No. of Unduplicated Individuals

Unit Type

Unit Quantity

SABG Expenditures

Other (please list)

169

SABG Table 4 - State Agency SABG Expenditure Compliance Report. This table provides a
description of SA Block Grant expenditures for authorized activities to prevent and treat
substance abuse from the fiscal year award three years prior to the fiscal year for which the State
is applying for funds.
SABG Table 4

State Identifier :

FY 2012 SA Block Gr ant Awar d

Expenditur e Categor y

Substance Abuse Pr evention* and Tr eatment

Pr imar y Pr evention

HIV Ear ly Inter vention Ser vices**

Tuber culosis Ser vices

Administr ation (excluding pr ogr am / pr ovider level)

Total
* Prevention other than Primary Prevention
** HIV Designated States

170

Primary Prevention Expenditures Checklists
SABG Table 5a - Primary Prevention Expenditures Checklist
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 Model
(IOM) should be directly associated with the cost of completing the activity or task, for example
information dissemination may 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 SABG Table
5a.

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.

SABG Table 5b - SABG Prevention Expenditures Checklist by Institute of Medicine Categories
(IOM) (Universal, Selective, Indicated)
If the State chooses to report substance abuse primary prevention activities utilizing the IOM Model
of Universal, Selective and Indicated, the State must complete SABG Table 5b. Indicate how much
funding supported each of the IOM classifications of Universal, Selective, or Indicated.
SABG Table 5c – SABG Primary Prevention Priorities and Special Population Categories
States should indicate each substance the state actually identified through their needs assessment as a
priority and the State addressed by checking (√) on SABG Table 5c each priority substance. States
should also check (√) on SABG Table 5c each special population the state identified along with the
priority substance that the State addressed utilizing substance abuse primary Prevention set-aside
dollars during the designated compliance year.
.

171

SABG Table 5a – SABG Primary Prevention Expenditures Checklist
SABG Table 5a

SABG Primary Prevention Expenditures Checklist

State Identifier:
Report Period- From:
Strategy
1. Infor mation Dissemination

2. Education

3. Alter natives

4. Pr oblem Identification and Refer r al

5. Community-Based Pr ocesses

6. Envir onmental

To:
A.
IOM Target

B.
SAPT Block Grant

C.
Other Federal

D.
State

E.
Local

F. Other

Universal

Selected

Indicated

Unspecified

Universal

Selected

Indicated

Unspecified

Universal

Selected

Indicated

Unspecified

Universal

Selected

Indicated

Unspecified

Universal

Selected

Indicated

Universal

Selected

172

7. Section 1926-Tobacco

8. Other

9. Suicide Pr evention

Indicated

Unspecified

Universal

Selected

Indicated

Universal

Selected

Indicated

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

173

SABG Table 5B. SABG Primary Prevention Expenditures by IOM Category –
SABG Table 5B.

SABG Primary Prevention Expenditures by IOM Category

State Identifier:
Report Period- From:

Activity

To:

FY 2011 SA
Block Gr ant
Awar d

Other
Federal

State Funds

Local Funds

Other

Universal Direct
Universal Indirect
Selective
Indicated

$
$
$
$

Column Total

Total SABG
Award

Planned Primary
Prevention
Percentage

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

174

SABG Table 5c- SABG Primary Prevention Targeted Priorities.
States should identify the categories of substances the State targeted with Primary Prevention setaside dollars from the FY 2011 SA Block Grant awards.

Targeted Substances
Alcohol
Tobacco
Marijuana
Prescription Drugs
Cocaine
Heroin
Inhalants
Methamphetamine
Synthetic Drugs (i.e. Bath salts,
Spice, K2)
Instructions: In the table below identify the special population categories the State plans to targets with
Primary Prevention set-aside dollars
Targeted Populations
Students in College
Military Families
LGBTQ
American Indians/Alaska Natives
African American
Hispanic
Homeless
Native Hawaiian/Other Pacific
Islanders
Asian
Rural
Underserved Racial and Ethnic
Minorities

175

SABG Table 6- SABG Resource Development Expenditures Checklist
Only complete this table if your State or Jurisdiction funded resource development activities with SA Block Grant
SABG Table 6

SABG Resource Development Expenditures Checklist

State Identifier:
Report Period- From:
Activity

To:
A. Treatment

B.
Prevention.

C.
Additional
Combined

D. 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

176

SABG Table 7 – Statewide Entity Inventor
SABG Table 7

SABG Statewide Entity Inventory

State Identifier:
Report Period- From:

Entity
Number

Total

I-SATS
ID
(For
SABG)

To:

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 and Prevention Intervention
Women
Services for
with
HIV
Dependent
Children

F
Adults
serious
mental
illness

$
$
$

CMHS Block Grant
G
H
Children
Nonwith a
Direct
serious
Services
emotional
disturbance

$
$
$

177

SABG Table 7 – Statewide Entity Inventor
SABG Tables 8a, 8b, 8c, and 8d -Maintenance of Effort for State Expenditures for Authorized
Activities to Prevent and Treat Substance Abuse and Related Public Health Services
SABG Table 8a, 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 Single State Agency (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

178

SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse Prevention and
Treatment
SABG Table 8a
State Identifier:
Report Period- From:

Total Single State Agency (SSA) Expenditur es for Substance Abuse Pr evention and Tr eatment
To:

Period

Expenditures

B1 (2011) + B2 (2012)
2

(A)

(B)

(C)

SFY 2012
(1)
SFY 2013
(2)
SFY 2014
(3)

Are the expenditure amounts reported in Columns B “actual” expenditures for the State fiscal years involved?
FY 2012
FY 2013
FY 2014

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.

179

SABG Table 8b - Statewide Non-Federal Expenditures for Tuberculosis to Individuals in Substance Use Disorder Treatment, Base and
Maintenance. Report all statewide, non-Federal funds expended on Tuberculosis (TB) services to individuals in substance use disorder treatment
during each State fiscal year (SFY).
SABG Table 8b

Statewide Non-Feder al Expenditur es for Tuber culosis Ser vices to Individuals in Substance Use Disor der Tr eatment

State Identifier :
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)

180

OMB No. 0930-0080
SABG Table 8b (Cont.)

Statewide Non-Feder al Expenditur es for Tuber culosis Ser vices to Individuals in Substance Use Disor der Tr eatment

State Identifier :
Repor t Per iod- From:

To:
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 2014
(2)

OMB No. 0930-0080
SABG Table 8c - State-wide Non-Federal 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 (Base) in box B2.
SABG Table 8c

Statewide Non-Feder al Expenditur es for HIV Ear ly Inter vention Ser vices to Individuals in Substance Use Disor der Tr eatment

State Identifier :
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
SABG Table 8c (Cont.)

Statewide Non-Federal Expenditures for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment

State Identifier
Report Period- From:

To:
MAINTENANCE
Period

(3)

SFY 2014

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

OMB No. 0930-0080
SABG Table 8d - Expenditures for Services to Pregnant Women and Women with Dependent Children, Base and Maintenance.

SABG Table 8d

Expenditur es for Ser vices to Pr egnant Women and Women with Dependent Childr en

State Identifier :
Repor t Per iod- From:

To:
Per iod

1994
2012
2013
2014

Total Women’s Base

Total Expenditur es

(A)

(B)

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 SABG Tables 9 through 13 as described below.
•

•

SABG Table 9 - 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 SABG Table 7, 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.
SABG Table 10 - 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).
SABG Table 11 - 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 2014 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.
SABG Table 12 – SABG 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.
SABG Table 13 - 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)

185

SABG Table 9 - Prevention Strategy Report
SABG Table 9
Report Period- From:

To:

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)

SABG Table 10 - Treatment Utilization Matrix
SABG Table 10
Report Period- From:
State Identifier

To:
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)

Standard Deviation of
Cost
(E)

Median Cost of Services
(D)

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

9. Opioid Replacement Therapy

Rehabilitation/Residential

Ambulatory (Outpatient)

SABG Table 11 - Unduplicated Count of Persons Served for Alcohol and Other Drug Use
SABG Table 11
Report Period- From:
State Identifier:

Age

To::

A. Total

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

25-44

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 SABG Table 10

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

SABG Table 12 - SABG HIV Designated States Early Intervention Services
SABG Table 12
Report Period- From:
State Identifier

To::

1. Number of SAPT HIV EIS programs funded in the State:

Early Intervention Services for Human Immunodeficiency Virus (HIV)
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:

SABG Table 13. 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
• SABG Table 14. - 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.
• SABG Table 15 - 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.
• SABG Table 16 - 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.
• SABG Table 17 – 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.
• SABG Table 18 - 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
• SABG Table 19 – 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
• SABG Table 20 - Retention. This table collects information regarding retention. Specifically,
this table collects information regarding the length of stay of clients completing treatment.
Prevention Performance Measures
• SABG Table 21. 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.
•

SABG Table 22. 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.

•

SABG Table 23. 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.
SABG Table 24. 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.
SABG Table 25. 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.

•
•

191

•
•
•
•

•
•

•

•
•
•

•

SABG Table 26. Employment/Education; Measure: Average Daily School Attendance Rate.
This table collects information regarding the average daily school attendance.
SABG Table 27. 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.
SABG Table 28. Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests.
This table collects information regarding alcohol- and drug-related arrests.
SABG Table 29. 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.
SABG Table 30. 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.
SABG Table 31. 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.
SABG Table 32. 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 population-based
programs. Population-based programs and strategies include planned and deliberate goaloriented practices, procedures, processes, or activities that have identifiable outcomes
achieved with a sequence of steps subject to monitoring and modification.
SABG Table 33. 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.
SABG Table 34. 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.
SABG Table 35. Number of Evidence-based Programs and Strategies, and Total SA Block
Grant Funds 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.
SABG Table 36: (Optional Worksheet) Program/Strategy Detail for Computing the Total
Number of Evidence-based Programs and Strategies, and for Reporting Total SA Block
Grant Funds Spent on substance abuse prevention Evidence-Based Programs and Strategies.
This table supports the computation of the total number of evidence-based programs and
strategies and the total SA Block Grant funds spent on substance abuse prevention evidencebased programs and strategies.

192

SABG Table 14 – 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 parttime) (prior 30 days) at admission vs. discharge

Admission
Clients (T1)

Discharge
Clients (T2)

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)

193

State Description of Employment\Education Status Data Collection (SABG Table 15)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Employment\Education Data Collection (SABG Table 15):
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 SABG Table 15 (select all that apply):
□ Client self-report □ Client self-report confirmed by another source→
Administrative data source □ Other Specify ___________________

EPISODE OF CARE

How is the admission/discharge basis defined for SABG Table 15 (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 SABG Table 15 (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 15 (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

□ collateral source □

194

SABG Table 15–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

Admission
Clients (T1)

Discharge
Clients (T2)

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

195

SABG Table 16– 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

Admission
Clients
(T1)

Discharge
Clients
(T2)

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

196

State Description of Criminal Involvement Data Collection (SABG Table 16)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Criminal Involvement Data Collection (SABG 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 SABG Table 16 (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 SABG 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 ___________________________________________
_________________________________________________________

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 SABG 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 SABG 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-entityspecific 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.

197

SABG Table 17– 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.

Admission
Clients
(T1)

Discharge
Clients
(T2)

Number of clients abstinent from alcohol [numerator]
Total number of clients with non-missing values on “used any alcohol” variable [denominator]
Percent of clients abstinent from alcohol
(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)

198

State Description of Alcohol Use Data Collection (SABG Table 17)
STATE
CONFORMANCE TO
INTERIM STANDARD

State Description of Alcohol Use Data Collection (SABG Table 17):
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 SABG Table 17 (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 SABG Table 17 (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 SABG Table 17 (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 SABG Table 17 (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-entityspecific 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.

199

SABG Table 18 – PERFORMANCE MEASURE
CHANGE IN ABSTINENCE -- OTHER DRUG USE (From Admission to Discharge)
Most recent year for which data are available: _____________

Drug Abstinence – Clients with no drug use (all clients regardless of primary problem) (use Any Drug
Admission
Discharge
Use in last 30 days field) at admission vs. discharge.
Clients (T1)
Clients (T2)
Number of Clients abstinent from illegal drugs [numerator]
Total number of clients with non-missing values on “used any drug” variable [denominator]
Percent of clients abstinent from drugs
(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)

200

State Description of Other Drug Use Data Collection (SABG Table 18)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Other Drug Use Data Collection (SABG 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 SABG Table 18 (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 SABG 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 ___________________________________________
How was discharge data collected for SABG 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 SABG 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-entityspecific 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.

201

SABG Table 19 – 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

Admission
Clients
(T1)

Discharge
Clients
(T2)

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 self-help
activities [denominator]
Percent of clients participating in self-help activities

202

State Description of Social Support of Recovery Data Collection (SABG Table 19)
STATE CONFORMANCE TO
INTERIM STANDARD

State Description of Social Support of Recovery Data Collection (SABG Table 19):
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 SABG Table 19 (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 SABG 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 SABG 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 SABG 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.
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.

203

SABG Table 20: 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)

MEDIAN (MEDIAN)

INTERQUARTILE RANGE

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

204

SABG T ABLE 21– SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: R EDUCED M ORBIDITY - ABSTINENCE FROM DRUG
USE /ALCOHOL USE
M EASURE : 30-DAY USE
A.
Measure

B.
Question/Response

C.
Pre-populated
Data

D.
Approved
Substitute Data

1. 30-day
Alcohol Use

Source Survey Item: NSDUH Questionnaire. “Think specifically about the
past 30 days, that is, from [DATEFILL] through today. During the past 30
days, on how many days did you drink one or more drinks of an alcoholic
beverage?” [Response option: Write in a number between 0 and 30.]
Outcome Reported: Percent who reported having used alcohol during the past
30 days.
Ages 12–20 - FFY 2011
Ages 21+ - FFY 2011
2. 30-day
Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that
Cigarette Use
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 2011
Ages 18+ - FFY 2011
3. 30-day Use of Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that
Other Tobacco
is, since [DATEFILL], on how many days did you use [other tobacco
Products
products]†?” [Response option: Write in a number between 0 and 30.]
Outcome Reported: Percent who reported having used a tobacco product
other than cigarettes during the past 30 days, calculated by combining
responses to questions about individual tobacco products (snuff, chewing
tobacco, pipe tobacco).
Ages 12–17 - FFY 2011
Ages 18+ - FFY 2011
4. 30-day Use of Source Survey Item: NSDUH Questionnaire: “Think specifically about the
Marijuana
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 2011
Ages 18+ - FFY 2011
5. 30-day Use of Source Survey Item: NSDUH Questionnaire: “Think specifically about the
Illegal Drugs
past 30 days, from [DATEFILL] up to and including today. During the past 30
Other Than
days, on how many days did you use [any other illegal drug]‡?”
Outcome Reported: Percent who reported having used illegal drugs other
Marijuana
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 2011
Ages 18+ - FFY 2011
†
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.

205

SABG T ABLE 22– 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 12–20 - FFY 2011
Ages 21+ - FFY 2011
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 2011
Ages 18+ - FFY 2011
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 2011
Ages 18+ - FFY 2011

2. Perception of
Risk From
Cigarettes

3. Perception of
Risk From
Marijuana

C.
Pre-populated
Data

D.
Approved
Substitute Data

206

SABG T ABLE 23– 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

B.
Question/Response

C.
Pre-populated
Data

D.
Approved
Substitute Data

1. Age at First
Use of Alcohol

Source Survey Item: NSDUH Questionnaire: “Think about the first time you
had a drink of an alcoholic beverage. How old were you the first time you had
a drink of an alcoholic beverage? Please do not include any time when you
only had a sip or two from a drink.” [Response option: Write in age at first
use.]
Outcome Reported: Average age at first use of alcohol.
Ages 12–20 - FFY 2011
Ages 21+ - FFY 2011
2. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the first
Use of
time you smoked part or all of a cigarette?” [Response option: Write in age at
Cigarettes
first use.]
Outcome Reported: Average age at first use of cigarettes.
Ages 12–17 - FFY 2011
Ages 18+ - FFY 2011
3. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the first
Use of Tobacco time you used [any other tobacco product]†?” [Response option: Write in age at
first use.]
Products Other
Than Cigarettes Outcome Reported: Average age at first use of tobacco products other than
cigarettes.
Ages 12–17 - FFY 2011
Ages 18+ - FFY 2011
4. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the first
Use of
time you used marijuana or hashish?” [Response option: Write in age at first
Marijuana or
use.]
Outcome Reported: Average age at first use of marijuana or hashish.
Hashish
Ages 12–17 - FFY 2011
Ages 18+ - FFY 2011
5. Age at First
Source Survey Item: NSDUH Questionnaire: “How old were you the first
Use of Illegal
time you used [other illegal drugs]‡?” [Response option: Write in age at first
Drugs Other
use.]
Than Marijuana Outcome Reported: Average age at first use of other illegal drugs.
or Hashish
Ages 12–17 - FFY 2011
Ages 18+ - FFY 2011
†
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.

207

SABG 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 DISAPPROVAL /ATTITUDES
A.
Measure
1. Disapproval of
Cigarettes

2. Perception of
Peer Disapproval
of Cigarettes

3. Disapproval of
Using Marijuana
Experimentally

4. Disapproval of
Using Marijuana
Regularly

5. Disapproval of
Alcohol

B.
Question/Response

C.
Pre-populated
Data

D.
Approved
Substitute Data

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 2011
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 2011
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 2011
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 2011
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 12–20 - FFY 2011

208

SABG T ABLE 25– 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 2011
Ages 18+ - FFY 2011

C.
Prepopulated
Data

D.
Approved
Substitute
Data

C.
Prepopulated
Data

D.
Approved
Substitute
Data

SABG T ABLE 26– 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 2011

209

SABG T ABLE 27 – 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

B.
Source

Alcohol-Related
Traffic Fatalities

Source: National Highway Traffic Safety Administration Fatality Analysis
Reporting System
Measure calculation: The number of alcohol-related traffic fatalities divided
by the total number of traffic fatalities and multiplied by 100.
FFY 2011

C.
Pre-populated
Data

D.
Approved
Substitute Data

SABG T ABLE 28– 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

C.
Pre-populated
Data

D.
Approved
Substitute Data

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 2011

210

SABG T ABLE 29 – SUBSTANCE ABUSE P REVENTION NOM S DOMAIN: SOCIAL C ONNECTEDNESS
M EASURE : F AMILY C OMMUNICATIONS AROUND DRUG AND ALCOHOL USE
A.
Measure

B.
Question/Response

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

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

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 2011
Source Survey Item: NSDUH Questionnaire: “During the past 12 months,
how many times have you talked with your child about the dangers or
problems associated with the use of tobacco, alcohol, or other drugs?”†
[Response options: 0 times, 1 to 2 times, a few times, many times]
Outcome Reported: Percent of parents reporting that they have talked to
their child.
Ages 18+ - FFY 2011

†

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.

SABG T ABLE 30 – 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

Question/Response

Pre-populated
Data

Approved
Substitute Data

Exposure to
Prevention
Messages

Source Survey Item: NSDUH Questionnaire: “During the past 12 months, do
you recall [hearing, reading, or watching an advertisement about the
prevention of substance use]†?”
Outcome Reported: Percent reporting having been exposed to prevention
message.
Ages 12–17 - FFY 2011
†
This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within a
specific context

211

SABG Tables 31-35 – Reporting Period
Reporting Period - Start and End Dates for Information Reported on SABG Tables 31, 32, 33, 34, and 35.
Instructions for completing reporting Start and End Dates
The following chart is for collecting information on the reporting periods for the data entered in SABG Tables 31, 32, 33, 34 and 35.
See: The instructions for and the data entered in SABG Tables 31, 32, 33, 34 and 35.
Rows 1 through 5 each correspond to a single form in the current year’s application among the following five tables: 31, 32, 33, 34 and
35.
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 SABG Tables 31, 32, 33, 34 and 35
Please indicate the reporting period (start date and end date totaling 12 months by the State)
for each of the following fNOMS. The start date and end date for NOMS 31-35 should be the same..
A. Reporting Period
B. Reporting Period
Tables
Start Date
End Date
1. S ABG Ta b le 31
Individual-Based Programs and Strategies –
Number of Persons Served by Age, Gender,
Race, and Ethnicity

mm/dd/yyyy

2. S ABG Ta b le 32
Population-Based Programs and Strategies
– Number of Persons Served by Age,
Gender, Race, and Ethnicity

mm/dd/yyyy

3. S ABG Ta b le 33 (Optional)
Number of Persons Served by Type of
Intervention

mm/dd/yyyy

4. S ABG Ta b le 34
Number of Evidence-Based Programs and
Strategies by Type of Intervention

mm/dd/yyyy

Da ta s u b m itte d o n S ABG
Ta b le 35 m u s 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 S ABG
Ta b le 34

Da ta s u b m itte d o n S ABG
Ta b le 35 m u s 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 S ABG Ta b le
34

5. S ABG Ta b le 35
Total Number of Evidence-Based Programs
and Total SAPT BG Dollars Spent on
Evidence-Based Programs/Strategies

212

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.

SABG Table 31 – 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

Total

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

213

SABG Table 32 – 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

214

SABG Table 33 (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

A.
Individual-Based
Programs and Strategies

B.
Population-Based Programs and
Strategies
N/A

N/A
N/A
N/A

5. Total

215

SABG Table 34 – SUBSTANCE ABUSE P REVENTION Evidence-Based Programs and Strategies by Type of Intervention

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

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

SABG Table 34– 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

B.
Universal
Indirect

C.
Universal
Total

D.
Selective

E.
Indicated

F.
Total

1. Number of Evidence-Based
Programs and Strategies Funded
2. Total number of Programs and
Strategies Funded
3. Percent of Evidence-Based
Programs and Strategies

216

SABG Table 35 – 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 evidence-based
Programs/Strategies

Universal Direct

Total #

Universal Indirect

Total #

Selective

Total #

Indicated

Total #

Total EBPs:

Total Dollars Spent: $

217

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 epopulated 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):

218

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

 No (Indicate frequency of data collection.)______________________

Are trend data available?
 Yes (Indicate start year of trend data.)_________________________  No
 Census

What is the mode of data collection?

 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

219

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:

220

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

 Ms.

 Dr.

 Other _____________________

Organization:

Department:

Mailing address:

E-mail address:
TELEPHONE:
FAX:

2. MEASURE(S) BEING APPEALED
National Outcome Measure(s) (NOM) being appealed:

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

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

4. ATTACH A COPY OF THE ORIGINAL SUBSTITUTION APPLICATION.

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

221

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:
FAX:
DATE

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

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

222

SABG Table 36: (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

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

223

File Type	application/pdf
File Title	TABLE 5A – Planned Primary Prevention Targeted Priorities – FY 2014
Author	DHHS
File Modified	2013-05-03
File Created	2013-05-03