Form CLI Part I CLI Part I CLI Part I

Strategic Prevention Framework State Incentive Grant (SPF SIG) Program

A1c - CLI Part I 7-22-13

SPF-SIG - Community

OMB: 0930-0279

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ATTACHMENT A1c: SPF SIG IV and V CLI Part I

Form Approved

OMB No. 0930-0279

Expiration Date XX/XX/XXXX

Strategic Prevention Framework
State Incentive Grant
(SPF SIG)

Cohort III & IV Cross-Site Evaluation
Community Level Instrument (CLI)
(Part I): Community Partner Activities
April 2013

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

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0279. Public reporting burden for this collection of information is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857

able of Contents

SPF SIG Cross-Site Evaluation, Community Level Instrument, Part I 3

Information and Directions 3

Definition of Terms 5

State/Tribe/Jurisdiction Level Questions 7

Information and Directions 7

Section 1: Record Identification and Reporting Period 7

Section 2: Subrecipient Monitoring Process 8

Section 3: Subrecipient Community Contact Information 9

Section 4: Subrecipient Organization Information 10

Section 4A: Organization Type and Funding 10

Section 4B: Cultural Competence Policies and Practices 15

Section 5: Strategic Prevention Framework 16

Section 5A. Needs and Resources Assessments 17

Section 5B. Capacity Building 23

Organizational Resources 24

Community Awareness 24

Relationship Building 26

Sustainability 27

Section 5C. Strategic Plan Development 27

Section 5D. Prevention Intervention Implementation 30

Section 5E. Monitoring and Evaluation 46

Section 6: Systems Factors 48

Section 7: Contextual Factors 49

Section 8: Training or Technical Assistance 50

Section 9: Closing Question 50

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

Information and Directions

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

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

Each subrecipient community will be assigned a unique identification. This identification will be used to link together all the data collected from a community throughout the grant period without the need to identify the community by name. In addition, no individuals will be identified in the reporting of results.

Sections 1–3 are to be answered by the primary grantee (that is, the state/tribe/jurisdiction) SPF SIG reviewer. This reviewer is someone who is directly involved with administering the SPF SIG grant to subrecipient communities, such as a Project Director. Sections 4–9 are to be answered by the subrecipient communities. Throughout sections 4–9, the term “you” refers to the subrecipient community that has received SPF SIG funding from the SPF SIG Primary Grantee. The subrecipient community could be an organization, coalition, or other entity.

Make sure to read all of the directions and examples, which are provided in italics. You are strongly encouraged to obtain input from others involved with the SPF SIG funded project. Each section of the instrument includes a list of individuals whom you may want to consider consulting in this data collection effort. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, such as the project coordinator, evaluator, intervention delivery staff, and others, as appropriate.

Prior to completing the survey, you may find it helpful to gather the following materials to help answer questions:

Budgets
Results of needs/resources assessments
Strategic plans
Meeting minutes
Memoranda of understanding
Prevention intervention implementation materials (curricula, programs, etc.)
Evaluation findings/reports
Organizational policies

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

If you need assistance in using the web-based data entry system, contact the Help Desk by phone at, 1 (888) DCAR-4-U or via email, [email protected]

There are several terms used throughout this instrument for which CSAP provides the definitions on the following pages.

Definition of Terms

Capacity building refers to activities conducted to improve the ability of an organization or community to deliver substance abuse prevention services, such as improving organizational resources; improving awareness about substance abuse problems; building new relationships or strengthening existing relationships among coalitions, groups, and organizations involved in substance abuse prevention; and working to ensure prevention intervention activities and outcomes continue after funding ends.
Community coalition is a union of people and organizations working for a common cause.
Community needs and resources assessments examine needs external to the organization and include community readiness, rates of substance use, prevention resources (e.g., call centers and trained counselors), partnerships, community prevention experience, and other monetary and non-monetary resources.
Community readiness is the community's level of awareness of, interest in, and ability and willingness to support substance abuse prevention initiatives. More broadly, connotes readiness for changes in community knowledge, attitudes, motives, policies, and actions.
Consequences are defined as the social, economic and health problems associated with the use of alcohol and illicit drugs e.g., illnesses related to alcohol (cirrhosis, fetal effects), drug overdose deaths, crime, and car crashes or suicides related to alcohol or drugs.
Consumption patterns are the way in which people drink, smoke and use drugs. Consumption includes overall consumption, acute or heavy consumption, consumption in risky situations (e.g., drinking and driving) and consumption by high-risk groups (e.g., youth, college students, and pregnant women).
Cultural competence is the attainment of knowledge, skills, and attitudes to enable administrators and practitioners to provide for diverse populations. This includes an understanding of that group’s or members’ language, beliefs, norms, and values, as well as socioeconomic and political factors that may have a significant impact on their well-being, and incorporating those variables into programs.
Environmental approaches are efforts to establish or change community standards, codes, and attitudes and thus influence incidence and prevalence of substance abuse. Approaches can center on legal and regulatory issues or can relate to service and action-oriented initiatives. Examples include TA to communities to maximize enforcement of laws governing availability and distribution of legal drugs, product pricing strategies, and modification of practices of advertising alcohol and tobacco.
Evaluation plans are systematic blueprints detailing all the evaluation aspects of the project including the database structures to manage the project data.
Intervening variables are factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of substance use and related risk behaviors and their subsequent consequences. These variables are the focus of prevention strategies, changes in which are then expected to affect consumption and consequences.
Intervention-level evaluation activities are activities to measure the impact and assess the implementation of specific interventions or strategies within the overall set of selected interventions.
Interventions are funded activities carried out under the auspices of the SPF SIG grant, and target a variety of subpopulations with the objective of improving substance use outcomes.
Key stakeholders are all of the members of the community who have a vested interest (a stake) in the activities or outcomes of a substance abuse intervention.
Logic models are graphic depictions of the components of a theory, program, initiative, or activity that shows the program's components and plausible linkages between the program components.
Media literacy programs foster the ability to analyze and evaluate messages in the media (e.g., working with children to teach them to evaluate the images and messages in a beer ad).
Organizational needs assessments examine an organization’s internal needs and include assessments of leadership, human resources, technical resources (e.g., telephones, computers, or appropriate software), infrastructure (e.g., facility, staff offices, conference rooms), funding sources, etc.
Prevention system is the entire set of agencies, organizations, and persons that contribute to efforts to prevent substance abuse and related problems within the community.
Primary grantee refers to the administrative entity of a jurisdiction (such as the state, tribe, or territory) receiving SPF SIG funds for delivery of substance abuse prevention programs.
Social marketing uses the principles of commercial marketing to develop, implement, and evaluate programs designed to influence the behavior of a target audience. Rather than dictating the way that information is to be conveyed, social marketing involves listening to the needs and desires of the target audience and building the program from there.
Strategic plans at a minimum will: specify the priorities that will be targeted; articulate a vision for activities to address needs; describe infrastructure needed to select and implement interventions; identify resources and training requirements; include plans for sustaining the infrastructure and services; and identify milestones and outcomes against which to gauge performance. Strategic plan development is Step 3 of the SPF.
Subrecipient communities are the entities (usually community based organizations, schools, or coalitions) that receive funds from the grantee to carry out SPF SIG activities or prevention interventions.
Sustainability is the process through which a prevention system becomes a norm and is integrated into ongoing operations. Sustainability is vital to ensuring that prevention values and processes are firmly established, that partnerships are strengthened, and that financial and other resources are secured over the long term.

State/Tribe/Jurisdiction Level Questions

To be answered for every reporting period by the state/tribe/jurisdiction level SPF SIG reviewer.

Information and Directions

Sections 1–3 are designed to gather information from the state/tribe/jurisdiction that is the primary grantee of a Strategic Prevention Framework State Incentive Grant (SPF-SIG) from CSAP. Its purpose is to ensure that the cross-site team has updated information about the subrecipient communities funded by the primary grantee and the procedures used to monitor subrecipients. Section 1 collects identification information about the primary grantee and Section 2 contains items describing procedures for monitoring subrecipient communities. Section 3 collects information about the subrecipient communities funded by the primary grantee and should be filled out for each subrecipient community.

After initial data entry, the primary grantee will only need to update the fields that have changed since the previous reporting period.

Section 1: Record Identification and Reporting Period

1. Primary Grantee Name: ^{B, F (autofill at F, locked)}

2. SPF-SIG Grant ID: ^{B, F (autofill at F, locked)}

3. Name of Primary Grantee Contact Person: ^{B, F
(autofill at F)}

4. Contact Phone Number: ^{B, F (autofill at F)}

5. Contact E-mail Address: ^{B, F (autofill at F)}

6. Mark the timeframe for which you are reporting.^{B, F}

October 1, 2012–September 30, 2013
October 1, 2013–September 30, 2014
October 1, 2014–September 30, 2015
October 1, 2015–September 30, 2016

Section 2: Subrecipient Monitoring Process

The questions in this section are designed to provide information about the processes and procedures used by the primary grantee to monitor its subrecipient communities.

7. As the primary SPF-SIG grantee, what procedure(s) do you follow in monitoring the SPF process at the subrecipient community level? (Select all that apply.)^{B, F}

Subrecipients must submit formal results of a needs and resources assessment.
Subrecipients must submit formal strategic plans.
Subrecipients must obtain approval of their strategic plans.
The primary grantee monitors the Subrecipients’ prevention intervention selection to ensure that interventions match the target outcomes and causal factors identified.
The primary grantee conducts prevention intervention-level evaluation.
The Subrecipient conducts its own evaluation and reports back to the primary grantee.
Other (Describe.)

8. Did you, as the primary grantee, select one or more substance abuse problem(s) that all funded subrecipient communities are targeting? (Select one response.)^B

The primary grantee selected 1 or more problems that all communities had to target. (Communities may or may not have been allowed to choose additional targets as well.)
The primary grantee selected a number of problems and communities could select which of these they would like to target.. (If selected you will automatically proceed to question 10.)
The primary grantee did not select problems that communities target (If selected you will automatically proceed to question 10.)

9. Indicate the substance abuse consumption patterns or consequences mandated for subrecipient focus. ^B

Underage use of alcohol
Any use of alcohol
Heavy use of alcohol
Binge drinking
Any use of tobacco under age 18
Any use of tobacco 18 years of age or older
Non-medical use of prescription drugs
Any use of illegal drugs
Motor vehicle crashes
Crime
Dependence or abuse
Alcohol-related morbidity/mortality
Tobacco-related morbidity/mortality
Drug-related morbidity/mortality
Other consumption patterns or consequences (Describe.)________________________

10. Are you allowing your subrecipient communities to proceed with subsequent steps of the Strategic Prevention Framework without conducting a community needs and resources assessment? (Select one response.)^B

11. During this reporting period, did you conduct an assessment of the training and technical assistance needs of the prevention workforce within your subrecipient communities? This assessment could be a formal process that involves interviews with key stakeholders and formal surveys or it could be an informal assessment of training needs among the prevention workforce. (Select one response.)^{B, F}

12. During this reporting period, were skills development and/or continuing education opportunities available to subrecipient communities for their prevention workforce? We are interested in opportunities funded by SPF SIG and other funding sources. Examples of workforce training opportunities might include continuing education credits offered for a seminar or workshop, or mandatory training on a new process or procedure being used in your state/tribe/jurisdiction for substance abuse prevention efforts. (Select one response.) ^{B, F}

13. Total number of subrecipient communities funded by this primary grantee: _____^{B, F}

Section 3: Subrecipient Community Contact Information

Questions 14–20 should be answered for each of the subrecipient communities funded by this primary grantee. The primary grantee will enter the name of each funded subrecipient community. Once entered, a unique identification code will be automatically generated and assigned to each funded subrecipient community. This identifier should remain unchanged throughout the life of the grant since it will be used to link together all the data received from that community. The names and unique identification codes of the subrecipient communities provided below will be used to construct a selection menu for entering CLI data. A subrecipient community for whom no information is provided by the primary grantee will not be able to access the online CLI data entry tool.

14. Name of the subrecipient community: (Up to 300 characters) ^{B, F (drop-down list derived from B data)}

15. Unique Identification Code of the subrecipient community: (Automatically generated)^{B, F (locked)}

16. Indicate the month and year this subrecipient community began receiving SPF SIG funds:^{B, F (autofill at F)}
MM/YYYY ____/______

17. Indicate the month and year SPF SIG funding for this subrecipient community is scheduled to end for the overall project. ^{B, F (autofill
at F)}
MM/YYYY ____/______

18. Name of the contact person for this subrecipient community: (Up to 75 Characters)^{B, F}^{(autofill at F)}

19. Telephone number for this contact person:^{B, F (autofill at
F)}

20. E-mail address for this contact person:^{B, F (autofill at
F)}

Section 4: Subrecipient Organization Information

This and subsequent sections are to be completed by each subrecipient, and asks questions that describe the subrecipient’s organization. The subrecipient’s organization should be identified in terms of the entity that will be carrying out the activities of the SPF SIG. Information about other funding sources and information about policies that have been developed that address cultural competence are collected in this section.

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

Project Director
Project Coordinator
Person with responsibility or knowledge of financial issues

Section 4A: Organization Type and Funding

Subrecipient Name (System pre-fill)^{B, F (locked)}

Unique Identifier of the Subrecipient (System pre-fill) ^{B,
F (locked)}

21. What type of organization would you say you are? You should identify your organization in terms of the entity that will be carrying out the activities of the SPF SIG. (Select one response that best describes your organization.) ^{B, F}

We are a Community Coalition and do not have any other organization type. (If selected, you will automatically proceed to question 23).
Non-youth-focused, local grassroots or community-based service and/or advocacy organization (e.g., substance abuse prevention organizations, HIV prevention organizations, YMCAs)
Faith-based organization
Youth-focused local grassroots or community-based service and/or advocacy organization (e.g., local chapter of Students Against Destructive Decisions, local youth councils, Boy Scouts/Girl Scouts, Big Brothers/Big Sisters)
Other non-profit organization, not listed above
School district
Law enforcement organization
College/university
Government agency
Local healthcare facility, treatment or prevention provider/facility (e.g., local hospital, community mental health center, local substance abuse prevention agency)
Other (Describe.)

22. Are you partnering with a Community Coalition? By partnering, we mean a formal relationship that is documented with a Memorandum of Understanding or similar agreement and/or to whom SPF SIG funding is provided. (Select one response.) ^B,
F

Yes (If selected, you will automatically proceed to Question 23.)
No (If selected, you will automatically proceed to Question 37.)

23. Describe the lead agency for the community coalition (the agency responsible for making the primary decisions of the coalition and/or the agency controlling the money)? (Provide a concise written description in the space available.) (500 character limit.)^{B, F (autofill at F)}

Statements 24 through 32 describe different structural and functional dimensions of a coalition. Please indicate whether you strongly agree, agree, neither agree nor disagree, disagree or strongly disagree with each statement as it pertains to your community coalition.

24. The coalition has a clear vision and focus. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

25. The coalition has collaborative leadership. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

26. Responsibilities among coalition members are fairly and effectively delegated. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

27. The coalition has a broad-based, diverse membership that represents the various groups and organizations involved in substance abuse prevention. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

28. Within the coalition, there is too much talking and not enough follow-through with actions. (Select one response.)^B,
F

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

29. The coalition has a process for tracking decisions. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

30. The coalition does not monitor whether or not there is follow-through on decisions. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

31. The coalition needs more structure in order to be effective. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

32. Denial and apathy among community members toward local substance use issues is a major barrier to our coalition’s effectiveness. (Select one response.)^{B, F}

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

33. What month and year was the community coalition established? (Provide MM/YYYY or select don’t know)^{B, F
(autofill at F)}

Specify Date (MM/ YYYY) )____/______
Don’t know

34. Indicate the role of the community coalition in changing community capacity, knowledge, norms and behaviors related to substance abuse prevention and program implementation. (Select all that apply.)^{B, F}

Collect and organize data
Conduct needs assessments
Train community members in substance abuse prevention
Leverage funds from sources other than the SPF SIG
Plan and/or implement prevention interventions
Ensure SPF SIG funded prevention intervention(s) address issues related to cultural competence
Plan and/or implement process or outcome evaluations of prevention interventions
Set substance abuse policy at the organizational, local, state, or tribal level
Educate others about needed changes in substance abuse policy at the organizational, local, or state/tribe/jurisdiction level
Other (Describe.)

35. Approximately how many different organizations are involved in this community coalition?^{B, F}
__________

36. Indicate the types of organizations or individuals that participate in the community coalition. (Select all that apply.)^{B, F}

 Youth groups/representatives

 Parents/family/caregiver groups

 Business community

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

School(s)/school districts

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

Scouts/Girl Scouts)

Law enforcement agency/agencies (e.g., local, tribal, state and Federal law enforcement agencies to include the police, FBI, DEA, and ATF)

 Local or state/tribe/jurisdiction courts

State Departments of Justice (e.g., Judicial Department, Dept of Juvenile Justice, Department of Criminal Justice, Attorney General’s Office)

 Federal Department of Justice (excluding their law enforcement arms mentioned above [i.e., FBI, DEA, ATF])

 State/tribal and/or local jails and prisons

 Faith-based organization(s) (e.g., churches or charitable organizations with religious

affiliations such as Catholic Charities)

 Civic or volunteer organization(s) (e.g., Kiwanis, Fraternal Order of Police, Women’s

League, local sports or neighborhood associations)

 Healthcare professionals

 Other State/tribe/jurisdiction government agencies (e.g., public health, public safety, social services, American Indian Tribal government)

 Local, village or tribal agencies (Mayor’s office, city council, tribal council, Alaska Native Corporation agencies)

 Other (Describe.) _________________________________________________

37. In addition to SPF SIG funding, what other types of funding for substance abuse prevention do you as the subrecipient organization (i.e, entity that will be carrying out the activities of the SPF SIG) currently receive? This question pertains to the funded organization as a whole, not just the specific SPF SIG prevention initiative. (Select all that apply.)^B,
F

We don't receive any funds in addition to the SPF-SIG funding
State, jurisdictional or tribal funds
County or municipal funds
Foundation funds
Private contributions from individuals
Corporate contributions
Federal Substance Abuse Prevention and Treatment Block Grant funds
Drug Free Communities funds
Safe and Drug Free Schools funds
SIG funds (this is funding that came from the first round of State Incentive Grants, and does not include current SPF SIG funding)
SIG planning funds
SIG enhancement funds
Community Anti-Drug Coalitions of America (CADCA)
Department of Justice, Office of Juvenile Justice and Delinquency Prevention funds
Weed and Seed
Medicaid
Other Federal funds (Describe.) ____________________________________
Other non-Federal funds (Describe.) ________________________________

Section 4B: Cultural Competence Policies and Practices

These questions collect information on how your subrecipient organization (i.e., entity that will be carrying out the activities of the SPF SIG) addresses cultural competence.

38. Does your organization have formal, written policies and practices in place to address cultural competence? For purposes of this question, we are only interested in those areas in which you have formal, written policies. There are many reasons an organization may not have formal, written policies in place to address cultural competence and your honest answer is valuable to the cross-site evaluation.(Select one response.)^{B, F}

Yes, we do have formal, written policies and practices to address cultural competence.
We do not have formal polices to address cultural competence but are required to follow the policies of the fiscal agency through which the SPF SIG funds are funneled. (If selected, you will automatically proceed to question 40.)
Not applicable—We are a coalition or other organization type that does not have formal policies. (If selected, you will automatically proceed to question 42.)
We are aware that cultural competence is an issue but we have not developed formal, written policies yet or these policies are currently being developed. (If selected, you will automatically proceed to question 42.)

39. Indicate the areas in which your organization has formal, written policies and practices in place to address cultural competence. (Select all that apply.)^{B, F}

Organizational administration (e.g., purchasing, contracting)
Board representation (e.g., board recruitment, board leadership)
Training and staff development
Language and internal and external communication (e.g., availability of interpreters, documents that avoid culturally insensitive language)
Service approach
Evaluation design
Data collection (qualitative and quantitative)
Other (Describe.) _____________________________________________________

40. How is compliance with cultural competence policies and/or practices monitored within your organization? (Select one response.)^{B, F}

Compliance is not monitored
Compliance is monitored once a year or less frequently by a director, executive, or administrator
Compliance is monitored twice a year or more often by a director, executive, or administrator
Compliance is monitored once a year or less frequently by someone other than a director, executive, or administrator
Compliance is monitored twice a year or more often by someone other than a director, executive, or administrator

41. If contract agencies are used, are they held to the same standards with regard to cultural competence? (Select one response.)^{B, F}

Not applicable—Contracted agencies are not used
Yes
No
Don’t know

Section 5: Strategic Prevention Framework

Each component of the Strategic Prevention Framework is addressed in this section.

The five steps include:

Needs and resources assessments
Capacity building
Strategic plan development
Prevention intervention implementation
Monitoring and evaluation

You will have the opportunity to describe your activities for each of the steps you worked on during this reporting period.

Section 5A. Needs and Resources Assessments

This section collects information on organizational and community needs and resources assessments you conducted during this reporting period. You are asked whether or not the needs and resources of your organization and the community have been assessed. It also provides you with an opportunity to describe the needs and resources that have been identified. Finally, the section asks about the consumption patterns, consequences, and populations you plan to target, based on the needs assessments.

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

Project Director
Project Coordinator
SEOW Liaison
Data Coordinator

42. Have you worked on any aspect of the Needs and Resource Assessment component of the SPF SIG framework during this reporting period?^{B, F}

Yes
No (If selected, you will automatically proceed to Question 59.)

43. Have you worked on assessing organizational needs and resources during this reporting period?Organizational needs assessments examine internal needs and include assessments of leadership, human resources, technical resources (e.g., telephones, computers, or appropriate software), infrastructure (e.g., facility, staff offices, conference rooms), funding sources, etc. ^{B, F}

Yes
No (If selected, you will automatically proceed to Question 46.)

44. Indicate the types of organizational needs and resources you assessed during this reporting period. This question is asking about the areas you considered or examined during this reporting period to determine the specific needs and resources you should be aware of. (Select all that apply.)^{B, F}

Mission/vision
Leadership ability
Cultural competence
Human resources
Technical resources
Infrastructure
Funding sources
Organizational experience
Up-to-date knowledge of substance abuse prevention
Other (Describe.) _____________________________________________________

45. Have you completed an organizational needs and resources assessment during this reporting period? Only answer “yes” if your assessment was completed during this reporting period. If the assessment was still being conducted at the end of the reporting period, select “no.” You will be able to answer “yes” and provide more detail in the next reporting period. (Select one response.)^{B, F}

46. Have you worked on assessing community needs and resources during this reporting period?A community needs and resources assessment examines needs external to the organization and includes community readiness, rates of substance use, prevention resources (e.g., call centers and trained counselors), partnerships, community prevention experience, and other monetary and non-monetary resources. ^{B, F}

Yes
No (If selected, you will automatically proceed to Question 49.)

47. Indicate the types of community needs and resources that were assessed during this reporting period. (Select all that apply.)^{B, F}

Data on populations not typically included in assessments (e.g., homeless, undocumented workers)
Substance use rates of the potential target population
Substance use consequences in the potential target population (e.g., alcohol-related mortality)
Factors that might cause, lead to, or promote substance use
Experience within the community of working with the potential target population (e.g., previous encounters with the target population perhaps in serving members with prevention services or in conducting outreach to this population).
Community readiness
Workforce training issues within the community (e.g., not enough slots in a community-college training program)
Prevention resources (e.g., call centers and trained counselors)
Cultural competence
Partnerships within the community
Other (Describe.) _____________________________________________________

48. For each of the types of data, please indicate whether or not you used the data in conducting your community needs and resources assessment and whether or not it was provided to you by the Epidemiology and Outcomes Workgroup (EOW). This would also include data that the EOW showed you how to access or use. (Select one per row.)^{B, F}

		Yes, the data were used	Yes, the data were used and provided by the EOW	No, the data were not used
48a.	Student school survey data			
48b.	School achievement data			
48c.	Community surveys			
48d.	Public health statistics (e.g., mortality rates due to drug overdose)			
48e.	Census data			
48f.	Interviews and/or focus groups			
48g.	Public meetings or forums			
48h.	Law enforcement data (e.g., drug arrests or drug trafficking)			
48i.	Department of Justice data (e.g., outcomes of criminal cases)			
48j.	Public safety data (e.g., number of automobile accidents caused by drinking and driving)			
48k.	Social norms data			
48l.	Other (Describe.)_________________			

49. Have you identified consumption patterns that you are going to target for substance abuse prevention? (Select one response.)^{B, F (autofill at F)}

Yes
No (If selected, You will automatically proceed to question 51.)

50a. Indicate the consumption patterns you are targeting: (Select all that apply.)If “any use of illegal drugs” is selected proceed to 50b otherwise proceed to 51. ^{B, F (autofill at F)}

Underage use of alcohol
Any use of alcohol
Heavy use of alcohol
Binge drinking
Any use of tobacco under age 18
Any use of tobacco 18 years of age or older
Non-medical use of prescription drugs
Any use of illegal drugs
Other consumption pattern (Describe)

50b. You indicated you are targeting the consumption pattern “Any use of illegal drugs.” Please specify the drug(s) targeted (Select all that apply):

All illegal drugs
Marijuana
Ecstasy
Cocaine
Crack cocaine
Heroin
Methamphetamine/Crystal meth
Other substances (Describe) ____________________________________

51. Have you identified consequences of substance use that you are targeting? (Select one response.)^{B, F (autofill at F)}

Yes
No (If selected, you will automatically proceed to question 53.)

52. Indicate the consequences you are targeting: (Select all that apply).^{B, F (autofill at F)}

Motor vehicle crashes
Crime
Dependence or abuse
Alcohol-related morbidity/mortality
Tobacco-related morbidity/mortality
Drug-related morbidity/mortality
Other consequences (Describe.) ________________________________________
Other consequences (Describe.) ________________________________________

53. Have you identified specific populations (e.g., Hispanics, middle school students, young adults) that you will be targeting for SPF SIG funded substance abuse prevention? Substance abuse prevention includes all substances, such as alcohol, tobacco, marijuana, methamphetamine, and cocaine. (Select one response.)^{B, F (autofill at F)}

Yes
No (If selected, you will automatically proceed to Question 56.)

54. Indicate the populations you will be targeting for substance abuse prevention. For this question, we would like to know if you have very specific groups of people at whom your prevention interventions will be aimed. For example, if you are delivering a prevention intervention to all middle schools in an area, then you would only select ”middle school students.” In this example, you would not have to select all the possible race/ethnicity categories that might be enrolled in the schools. If, however, you are delivering a prevention intervention specifically designed to target pregnant Latinas, then you would select Hispanic and pregnant women. (These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.).^{B, F (autofill at F)}

African American
American Indian/ Alaska Native
Asian/ Pacific Islander
White
Hispanic
Elementary school students
Middle school students
High school students
College students
Under 18
Under 21
Young adults aged 18-25
Adults between ages 26 and 55
Adults older than 55
Construction workers
Pregnant women
Parents
Gay/ Lesbian/ Bisexual/ Transgender/ Men who have sex with men/ Women who have sex with women
Other target population (Describe.) _____________________________________
Other target population (Describe.) _____________________________________

55. You indicated you are targeting specific consumption patterns or consequences within specific target populations. Below you will find the list of consumption patterns and/or consequences you are targeting. Please match the target populations with the specified consumption patterns and consequences. For example, if you indicated that you are targeting any underage tobacco use and binge drinking, and you indicated that you are targeting high school students and college students, clarify if the tobacco use is targeted to high school students and/or college students, and whether the binge drinking is targeted to one or both groups.^{B,
F (autofill at F)}

Note: Only consumption patterns or consequences selected in Q. 50 and 52 will show as column headings, and only target populations selected in Q 54 will show in each row.

	1^st Consumption or Consequence	2^nd Consumption or Consequence	Etc.
1^st Target Population			
2^nd Target Population			
Etc.			

56. Have you identified specific intervening variables (e.g., access, social norms, individual factors) that you will be targeting for SPF SIG funded substance abuse prevention? Substance abuse prevention includes all substances, such as alcohol tobacco, marijuana, methamphetamine, and cocaine.

Yes
No (If selected, you will automatically proceed to question 59.)

57. Indicate the intervening variables you will be targeting for substance abuse prevention. (Select all that apply)

Level of enforcement
Social access
Retail access
Norms
Perception of risk of detection of getting caught
Perception of risk and harm
Promotion
Individual factors
Price
Availability of pro-social activities
School policies
Community and coalition development
Other intervening variable (Describe.)
Other intervening variable (Describe.)

58. You indicated you are targeting specific intervening variables and consumption patterns or consequences. Below you will find the list of consumption patterns and/or consequences you are targeting. Please indicate which intervening variables you believe influence which of your specified consumption patterns and consequences. For example, if you identified “level of enforcement” as an intervening variable and you are targeting any underage tobacco use and binge drinking, clarify if the level of enforcement intervening variable is linked to underage tobacco use or to binge drinking, or both. ^{B,
F (autofill at F)}

Note: Only consumption patterns or consequences selected in Q. 50 and 52 will show as column headings, and only intervening variables selected in Q 57 will show in each row.

	1^st Consumption or Consequence	2^nd Consumption or Consequence	Etc.
1^st Intervening Variable			
2^nd Intervening Variable			
Etc.			

Section 5B. Capacity Building

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

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

Project Director
Project Coordinator
Human Resources
Staff responsible for renting space, purchasing equipment, etc.
Intervention delivery staff
Coalition representatives
Evaluator

59. Have you worked on any aspect of the Capacity Building component of the SPF SIG framework during this reporting period?^B,
F

Yes
No (If selected, you will automatically proceed to Question 70.)

Organizational Resources

This section collects information on the activities you conducted to improve organizational resources within your organization such as writing mission or vision statements, identifying goals and activities, hiring and training staff, identifying leaders, obtaining physical space for the prevention intervention, etc.

60. Have you conducted activities to improve organizational resources during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to question 62.)

61. Indicate the activities you conducted during this reporting period to improve organizational resources. (Select all that apply.)^{B, F}

Wrote, reviewed or rewrote organizational or coalition mission/vision
Identified key organizational or coalition activities and goals
Hired staff
Trained staff
Identified coalition leader(s)
Improved cultural competence
Identified or secured physical space
Coordinated or improved technical resources
Coordinated data collection and/or management information systems (MIS) plans
Other: (Describe.)________________________________________________

Community Awareness

This section collects information about your efforts in raising awareness of substance abuse problems in the community, the types of substance abuse problems/issues for which you are raising awareness, the community members/groups you have targeted for awareness efforts, and activities you are conducting to raise awareness.

62. Did you work to raise community awareness of substance use or abuse problems during this reporting period? Awareness raising activities are considered those activities where your primary purpose is to draw attention to a substance abuse problem (underage drinking, methamphetamine use, etc.) or to your prevention efforts. These activities are not intended to recruit participants or volunteers, although that may happen. (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to question 66.)

63. Indicate the substance abuse problems or prevention efforts you are attempting to raise awareness of in the community. (Select all that apply.) ^{B, F}

Substance use rates or trends
Consequences related to substance use, such as crashes or arrests for drunk driving
Intervening variables associated with substance use and consequences
Coordination among agencies
Funding for substance abuse prevention
Other (Describe.)______________________________________________________

64. Indicate the community members and/or groups (i.e., target audience) to whom you are presenting awareness raising information. (Select all that apply.) ^{B, F}

 The general public

 Youth groups/representatives

 Parents/family/caregiver groups

 Business community

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

School(s)/school districts

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

Scouts/Girl Scouts)

Law enforcement agency/agencies (e.g., local, tribal, state and Federal law enforcement agencies to include the police, FBI, DEA, and ATF)

 Local or state/tribe/jurisdiction courts

State Departments of Justice (e.g., Judicial Department, Dept of Juvenile Justice, Department of Criminal Justice, Attorney General’s Office)

 Federal Department of Justice (excluding their law enforcement arms mentioned above [i.e., FBI, DEA, ATF])

 State/tribal and/or local jails and prisons

 Faith-based organization(s) (e.g., churches or charitable organizations with religious

affiliations such as Catholic Charities)

 Civic or volunteer organization(s) (e.g., Kiwanis, Fraternal Order of Police, Women’s

League, local sports or neighborhood associations)

 Healthcare professionals

 Other State/tribe/jurisdiction government agencies (e.g., public health, public safety, social services, American Indian Tribal government)

 Local, village or tribal agencies (Mayor’s office, city council, tribal council, Alaska Native Corporation agencies)

 Other (Describe.)

65. Indicate the activities that are being conducted to raise awareness of the substance abuse problems or prevention efforts to your target audience (Select all that apply.)^{B, F}

Media activities such as television, radio, or newspaper advertisements or public service announcements
Internet activities such as list servs, web sites, or mass e-mails to targeted populations
Direct mailings
Face-to-face outreach such as health fairs, classroom visits, other community events, etc.
Other: (Describe.) ____________________________________________________

Relationship Building

This section collects information on how you identified potential partners to join your SPF SIG partnership or participate in prevention intervention activities.

66. Have you identified key stakeholders, partners and partner organizations to participate in your SPF SIG prevention intervention activities? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to question 68.)

67. Check each type of organization you have partnered with during this reporting period.^{B, F}

 Youth groups/representatives

 Parents/family/caregiver groups

 Business community

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

School(s)/school districts

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

Scouts/Girl Scouts)

Law enforcement agency/agencies (e.g., local, tribal, state and Federal law enforcement agencies to include the police, FBI, DEA, and ATF)

 Local or state/tribe/jurisdiction courts

State Departments of Justice (e.g., Judicial Department, Dept of Juvenile Justice, Department of Criminal Justice, Attorney General’s Office)

 Federal Department of Justice (excluding their law enforcement arms mentioned above [i.e., FBI, DEA, ATF])

 State/tribal and/or local jails and prisons

 Faith-based organization(s) (e.g., churches or charitable organizations with religious

affiliations such as Catholic Charities)

 Civic or volunteer organization(s) (e.g., Kiwanis, Fraternal Order of Police, Women’s

League, local sports or neighborhood associations)

 Healthcare professionals

 Other State/tribe/jurisdiction government agencies (e.g., public health, public safety, social services, American Indian Tribal government)

 Local, village or tribal agencies (Mayor’s office, city council, tribal council, Alaska Native Corporation agencies)

 Other (Describe.)

Sustainability

This section asks about things you have done to ensure that prevention intervention activities and outcomes continue once SPF SIG funding ends. These efforts might focus on ensuring continued funding, structures, networks, partnerships, leadership, and resources.

68. Have you worked during this reporting period to ensure that the prevention intervention activities and outcomes continue when SPF SIG funding ends? (Select one response.)^{B, F}

Yes
No (If selected, You will automatically proceed to question 70)

69. How have you worked to ensure that prevention intervention activities and outcomes continue after SPF SIG funding has ended? (Select all that apply.) ^{B, F}

Leveraged other funding sources
Worked to ensure that prevention intervention activities are incorporated into the missions/goals and activities of other organizations (e.g., school districts, law enforcement agency)
Worked to gain formal adoption of prevention intervention activities into other organizations’ practices (e.g., school district curriculum, organizational policy change)
Worked to implement local level laws, policies or regulations to guarantee the continuation of prevention intervention activities
Worked on developing a coalition structure that will continue to function beyond the end of the grant period
Other (Describe.)____________________________________

Section 5C. Strategic Plan Development

This section collects information on the development of your strategic plan, including what is addressed in the plan and who has contributed to the plan at the local level.

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

Project Director
Project Coordinator
Coalition Members

70. Have you worked on any aspect of the Strategic Plan Development component of the SPF SIG framework during this reporting period?^{B, F}

Yes
No (If selected, you will automatically proceed to Question 77.)

71. Have you completed a strategic plan during this reporting period? If you are still working on a Strategic Plan, you will have the opportunity to report this information in a later reporting period. (Select one response.)^{B, F}

Yes
No, Strategic Plan was completed in an earlier reporting period (If selected, you will automatically proceed to question 77.)
No, Strategic Plan has not been completed (If selected, you will automatically proceed to question 77.)

72. Who worked on the strategic plan? (Select all that apply.) ^B,
F

 The general public

 Youth groups/representatives

 Parents/family/caregiver groups

 Business community

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

 Advocacy volunteers

School(s)/school districts

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

Scouts/Girl Scouts)

Law enforcement agency/agencies (e.g., local, tribal, state and Federal law enforcement agencies to include the police, FBI, DEA, and ATF)

 Local or state/tribe/jurisdiction courts

State Departments of Justice (e.g., Judicial Department, Dept of Juvenile Justice, Department of Criminal Justice, Attorney General’s Office)

 Federal Department of Justice (excluding their law enforcement arms mentioned above [i.e., FBI, DEA, ATF])

 State/tribal and/or local jails and prisons

 Faith-based organization(s) (e.g., churches or charitable organizations with religious

affiliations such as Catholic Charities)

 Civic or volunteer organization(s) (e.g., Kiwanis, Fraternal Order of Police, Women’s

League, local sports or neighborhood associations)

 Healthcare professionals

 Other State/tribe/jurisdiction government agencies (e.g., public health, public safety, social services, American Indian Tribal government)

 Local, village or tribal agencies (Mayor’s office, city council, tribal council, Alaska Native Corporation agencies)

 Local evaluator

Other (Describe.)__________________________________________________

73a. Which of the following does the strategic plan address or include? (Select all that apply.)^{B, F}

Indicators on substance abuse
Data on factors causing, leading to, or promoting substance use
Underage drinking initiative
Cultural competence
Connection with state SPF SIG initiative
Current community resources/strengths
Identification of conditions outside the scope of the prevention intervention (e.g., poverty rates, immigration trends, laws) that might affect it
Logic model
Necessary infrastructure development
Role of stakeholders
Appropriate prevention intervention selected to match target outcomes or causal factors
Barriers to implementation
Measurable objectives
Identification of available data sources to measure objectives
Data collection plans
Data monitoring plans
Data analysis plans
Sustainability
Opportunities for adjustments based on initial outcomes
Other (Describe)

73b. You indicated that the strategic plan addresses or includes a logic model. Does the strategic plan also include a way to evaluate the relationships, activities, and outcomes illustrated in the logic model? (Select one.)

74. Has your strategic plan been reviewed by the agency responsible for the SPF SIG initiative in your state/tribe/jurisdiction? (Select one response.)^{B, F}

75. Have you received feedback on your strategic plan by the agency responsible for the SPF SIG initiative in your state/tribe/jurisdiction? (Select one response.)^{B, F}

76. Has your strategic plan been approved by the agency responsible for the SPF SIG initiative in your state/tribe/jurisdiction? (Select one response.)^{B, F}

Not applicable—Our state/tribe/jurisdiction does not require or provide approval of the strategic plan.
Yes
No

Section 5D. Prevention Intervention Implementation

This section collects information about the prevention intervention(s) you selected for implementation in your community. A prevention intervention is an activity or set of activities to which a group is exposed in order to change the group's behavior. In substance abuse prevention, interventions are used to prevent or lower the rate of substance abuse or substance abuse-related problems.

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

Project Director
Project Coordinator
State Epidemiology Workgroup (SEOW) Liaison
Intervention delivery staff

77. Did you or your community partners deliver any single or multi-strategy prevention interventions during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 164.)

78. Did you or your community partners deliver any environmental prevention interventions or multi-strategy interventions that included an environmental strategy during this reporting period?^{B, F}

Yes
No (If selected, you will automatically proceed to Question 163.)

The questions that follow are an attempt to provide an exhaustive list of potential environmental interventions or strategies. The list is meant to provide a standard way of reporting on environmental strategy implementation and activities. You will not be penalized if you indicate “no” as a response option. There is space at the end of this section to report on environmental strategies that are not listed here. Throughout this section, “you” refers to your organization, or partners with your organization. For example, if you worked with the police department to conduct more sobriety checkpoints, you would report this activity on this form.

In questions 79a-l, please indicate which of the following type(s) of environmental strategies you worked to implement or implemented during this reporting period related to policy. For each environmental strategy you worked on you will also indicate the progress made.

79a. Did you work to enact open container laws prohibiting alcohol consumption in public places during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79b. Did you work to enact limits on the location, density, and hours of operation of liquor stores during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79c. Did you work to enact zoning ordinances to prohibit new alcohol outlets during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79d. Did you work to enact limits on smoking in public places (e.g., movie theaters and restaurants) during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79e. Did you work to enact limits on the use and placement of cigarette vending machines during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79f. Did you work to enact regulations on alcohol or tobacco advertising and billboard placements in the community during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79g. Did you work to establish drug/alcohol/tobacco-free school zones and/or school use policies during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79h. Did you work to establish drug/alcohol/tobacco-free workplaces and/or workplace use policies during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79i. Did you work to enact policies to reduce the problems/consequences associated with substance abuse (e.g., crime, driving under the influence, etc.) during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79j. Did you work to implement organizational policies (e.g., within recreation leagues, summer camps, other non-governmental organizations) to reduce drug/alcohol/tobacco use among staff and youth during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79k. Did you work to implement keg registration during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes, and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

79l. Did you conduct other policy prevention interventions during this reporting period? (Select one response.)^{B, F}

No
Not applicable. This type of policy was in place prior to receipt of SPF SIG funding.
Yes and the effort was successful.
Yes, we made some progress in this effort during this reporting period but we still have some work to do.
Yes, we worked on it but the effort was unsuccessful.

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

80. Did you contact your elected officials (e.g., to prohibit alcohol consumption and smoking in public places) during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 83.)

81. How many elected officials were contacted during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

82. How many issues did you contact your elected officials about during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

83. Did you provide information to elected officials about policies to be enacted (e.g., to prohibit new alcohol outlets in the community) during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 86.)

84. How many elected officials were provided information during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

85. How many policies did you provide information on during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

86. Did you organize a ballot initiative during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 88.)

87. How many ballot initiatives were organized during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

88. Did you work with school administrators and teachers to implement or revise a drug-free policy during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 90.)

89. How many schools did you engage in policy implementation or revisions during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

90. Did you work with businesses to establish a drug-free workplace or drug-free workplace policies during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 92.)

91. How many businesses did you engage in policy implementation during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

92. Did you conduct other activities to affect policy change during this reporting period? (Select one response.)^{B, F}

No (If selected, you will automatically proceed to Question 94.)
Yes (Describe.) (3000 character limit.) ___________________________________

93 How often did you conduct other policy activities during this reporting period? ^{B, F}

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

94. Did you conduct compliance checks that target merchants who sell alcohol and tobacco to minors during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 96.)

95. How many compliance checks were conducted during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

96. Did you establish sobriety checkpoints during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 99.)

97. How many sobriety checkpoints were established during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

98. Provide the frequency of checkpoints during this reporting period.^{B, F}

99. Did you set up surveillance of areas known for illegal drug sales during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 102.)

100. How many areas were targeted for surveillance during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

101. Provide the frequency of the surveillance during this reporting period. ^{B, F}

102. Did you work to increase building inspections during this reporting period from the number of inspections conducted prior to this reporting period? (Select one response.)^{B, F}

103 Did you work to ensure that policies to force landlords to improve or demolish run-down buildings were enforced during this reporting period? (Select one response.)^{B, F}

104. Did you make use of civil and criminal "nuisance abatement" statutes, which require landlords to evict tenants involved in narcotics-related activities or risk personal prosecution during this reporting period? (Select one response.)^{B, F}

105. Did you enforce policies to reduce the problems/consequences associated with substance abuse during this reporting period? (Select one response.)^{B, F}

106. Did you implement or work to implement other enforcement strategies during this reporting period? (Select one response.)^{B, F}

No (If selected, you will automatically proceed to Question 108.)
Yes (Describe.) (3000 character limit.) ____________________________________

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

Indicate which of the following activities you conducted during this reporting period in order to affect the implementation of environmental strategies related to enforcement.

108. Did you educate law enforcement during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 111.)

109. How many law enforcement education sessions were conducted during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

110. How many law enforcement officers were educated during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

111. Did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community for sting operations, sobriety check-points, etc.) during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 113.)

112. How many law enforcement officers were engaged in collaboration during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

113. Did you conduct citizen patrols in neighborhoods known for illegal drug sales during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 116.)

114. How many citizen patrols were conducted during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

115. How many neighborhoods known for illegal drug sales were patrolled during this reporting period? This response should be written as a whole number (e.g.,4).^{B, F}

116. Did you collaborate with municipal officials and private landlords to improve, rebuild, or raze abandoned buildings that are used to engage in drug use, adolescent alcohol use, and other illegal activities during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 119.)

117. How many municipal officials were engaged in collaboration during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

118. How many private landlords were engaged in collaboration during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

119. Did you conduct server-training programs that work with bartenders and wait staff to reduce service to minors and intoxicated customers during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 122.)

120. How many server-training programs were offered during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

121. How many bartenders/wait staff were trained during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

122. Did you educate merchants about the laws and penalties for selling to underage customers during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 125.)

123. How many merchant training programs were offered during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

124. How many merchants were educated about the laws and penalties for selling to underage customers during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

125. Did you conduct other activities to affect the implementation of enforcement activities during this reporting period? (Select one response.)^{B, F}

No (If selected, you will automatically proceed to Question 127.)
Yes (Describe.) (3000 character limit.) ____________________________________

126. How often did you conduct the other enforcement activities during this reporting period? ^{B, F}

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

127. Did you engage in social marketing during this reporting period? Social Marketing is using the principles of commercial marketing to develop, implement, and evaluate programs designed to influence the behavior of a target audience. Rather than dictating the way that information is to be conveyed, social marketing involves listening to the needs and desires of the target audience and building the program from there. (Select one response.)^{B, F}

Yes
No (If no, skip to question 138.)

128. How many social marketing campaigns were implemented during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

129. How many television ads were created during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

130. How many television ads were aired during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

131. How many radio ads were created during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

132. How many radio ads were aired during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

133. How many print ads were created during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

134. How many print ads were published during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

135. How many special events (e.g., drug-free concert, smoke-free sponsored softball tournament) were hosted during this reporting period, as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

136. How many other promotional activities (e.g., providing smoke-free pamphlets at a fair, distributing drug-free book covers at a school) were hosted during this reporting period as part of your social marketing campaigns? This response should be written as a whole number (e.g., 4).^{B, F}

137. How many promotional items were distributed during this reporting period, as part of your social marketing campaigns? Promotional items include pamphlets, brochures, leaflets, posters, videos or DVDs, and newsletters. This response should be written as a whole number (e.g., 4).^{B, F}

138. Did you engage in media literacy efforts during this reporting period? Media literacy programs foster the ability to analyze and evaluate messages in the media (e.g., working with children to teach them to evaluate the images and messages in a beer ad). (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 140.)

139. How many media literacy-building sessions were held during this reporting period? A session is considered one class or gathering of participants. For example, if a prevention intervention provides a class on tobacco ads and a class on alcohol ads that would count as two sessions. This response should be written as a whole number (e.g., 4).^{B, F}

140. Did you conduct other communication strategies during this reporting period? (Select one response.)^{B, F}

No (If selected, you will automatically proceed to Question 142.)
Yes (Describe.) (3000 character limit.) _____________________________________

141. How often did you conduct other communication strategies during this reporting period? ^{B, F}

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

142. Did you present at community meetings (e.g., PTA meetings, town hall meetings, school assemblies) during this reporting period? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 145.)

143. How many community meetings were presented at during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

144. What was the total number of participants at all community meetings where you presented during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

145. Did you send letters to the editor of the local newspaper or community newsletters during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 148.)

146. How many letters were sent during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

147. How many letters were published during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

148. Did you develop substance abuse prevention public service announcements (PSAs) during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 150.)

149. How many PSAs were developed during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

150. Did you broadcast substance abuse prevention public service announcements (PSAs) during this reporting period? (Select one response.)^{B, F}

No (If selected, you will automatically proceed to Question 152.)

151. How often were the PSAs broadcast during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

152. Did you produce and/or distribute substance abuse prevention posters this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 155.)

153. How many posters were distributed this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

154. How many weeks are the posters scheduled to be displayed this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

weeks

155. Did you launch a prevention-focused Web site(s) during this reporting period? (Select one response.)
^{B, F}

Yes
No (If selected, you will automatically proceed to Question 160.)

156. What is the number of visitor sessions (visits) that the Web site(s) had during this reporting period? This response should be written as a whole number (e.g., 4). ^{B, F}

Specify number of visits _____
Do not know

157. How many new (versus returning) visitors did the Web site(s) have during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

Specify number of new visitors _____
Do not know

158. What is the total number of unique page views that the Web site(s) had during this reporting period? This response should be written as a whole number (e.g., 4).^{B, F}

Specify number of unique page views _______
Do not know

159. What was the average amount of time spent on the Web site(s) during this reporting period? This response should be written in the hours:minutes:seconds format (e.g., 00:14:30 means that the average amount of time spent on the Web site was 14 minutes and 30 seconds).^{B, F}

Specify time spent (hours:minutes:seconds) ___ : ___ : ___
Do not know

160. Did you conduct other activities to affect the implementation of communication strategies during this reporting period? (Select one response.)^{B, F}

No (If selected, you will automatically proceed to Question 163.)
Yes (Describe.) (3000 character limit.) _____________________________________

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

162. Describe any other type(s) of environmental strategies you worked to implement or implemented during this reporting period that do not fall into the categories listed above. ^{B, F}

(Provide a concise written description in the space available.) (3000 character limit.)

163. Name all the prevention intervention(s) and corresponding strategies you or your community partners delivered during this reporting period. A prevention intervention may be comprised of a single strategy or a set of multiple strategies. If you are implementing a prevention intervention that is single strategy or a prevention intervention that incorporates more than one strategy, you must list each strategy separately. If an intervention incorporates more than one strategy of the same type it also must be listed as a separate strategy. ^{B, F}

For each strategy identified, a strategy type must be selected. Strategy choices include:

Prevention Education
Alternative Drug Free Activities
Problem Identification and Referral
Community-based Processes
Environmental
Information Dissemination
Other Activities Delivered to Individuals
Other Activities Not Delivered to Individuals

For example, CMCA—Responsible Beverage Server Training would be designated as an Environmental Strategy, CMCA —Social Marketing Campaign would be designated as an Environmental Strategy, and CMCA—College Collaboration Team would be designated as Community-based Process.

For each strategy named, the respondent will need to complete a CLI Part II form. The type of strategy will determine the sub-set of questions specific to the strategy the respondent must complete. Information collected on each strategy will include date of implementation, numbers of groups and participants served, frequency of activities, and gender, age, race, and ethnicity of population served/affected.

Prevention Intervention Name	Strategy Name	Strategy Type
Example 1: White Bison	Sons and Daughters of Tradition	 Prevention Education  Alternative Drug-free Alternative  Problem Identification and Referral  Community-based Process  Environmental  Information Dissemination  Other Activities Delivered to Individuals  Other Activities Not Delivered to Individuals
Example 1: White Bison	Coalitions as Clans training	 Prevention Education  Alternative Drug-free Alternative  Problem Identification and Referral  Community-based Process  Environmental  Information Dissemination  Other Activities Delivered to Individuals  Other Activities Not Delivered to Individuals
Example 2: Guiding Good Choices	Guiding Good Choices	 Prevention Education  Alternative Drug-free Alternative  Problem Identification and Referral  Community-based Process  Environmental  Information Dissemination  Other Activities Delivered to Individuals  Other Activities Not Delivered to Individuals

Prevention Intervention Name

Strategy Name

Strategy Type

Example 3: Social Marketing

Those Who Host campaign (parents)

 Prevention Education

 Alternative Drug-free Alternative

 Problem Identification and Referral

 Community-based Process

 Environmental

 Information Dissemination

 Other Activities Delivered to Individuals

 Other Activities Not Delivered to Individuals

Most of Us social norms campaign (youth)

 Prevention Education

 Alternative Drug-free Alternative

 Problem Identification and Referral

 Community-based Process

 Environmental

 Information Dissemination

 Other Activities Delivered to Individuals

 Other Activities Not Delivered to Individuals

Prevention Intervention Name	Strategy Name	Strategy Type
Example 4: CMCA	Responsible Beverage Server Training	 Prevention Education  Alternative Drug-free Alternative  Problem Identification and Referral  Community-based Process  Environmental  Information Dissemination  Other Activities Delivered to Individuals  Other Activities Not Delivered to Individuals
	Social Marketing Campaign	 Prevention Education  Alternative Drug-free Alternative  Problem Identification and Referral  Community-based Process  Environmental  Information Dissemination  Other Activities Delivered to Individuals  Other Activities Not Delivered to Individuals
	College Collaboration Team	 Prevention Education  Alternative Drug-free Alternative  Problem Identification and Referral  Community-based Process  Environmental  Information Dissemination  Other Activities Delivered to Individuals  Other Activities Not Delivered to Individuals

Section 5E. Monitoring and Evaluation

This section collects information on your development of an evaluation plan. You are also asked to indicate whether a final evaluation report was developed and if key findings from the evaluation were distributed to key stakeholders and/or key informants.

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

Project Director
Project Coordinator
Evaluator

164. Have you developed an evaluation plan? (Select one response.)^{B, F}

165. Was the implementation of your prevention interventions monitored by the state/tribe/jurisdiction level agency in charge of the SPF SIG funding during this reporting period? (Select one response.)^{B, F}

Not applicable—no prevention interventions were implemented during this reporting period
Yes, were implemented and monitored during the reporting period.
Implementation of some prevention interventions was monitored, but not all interventions were monitored.
Don’t know

166. Have you worked on any aspect of the Monitoring and Evaluation component of the SPF SIG framework during this reporting period?^{B, F}

Yes
No (If selected, you will automatically proceed to Question 172.)

167. Did you work on intervention level evaluation activities during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 172.)

168. Did you or the Primary Grantee develop any evaluation reports during this reporting period? Evaluation reports could take the form of letters, emails, formal reports, presentations or other formats. (Select one response.) ^{B, F}

169. Did you or the Primary Grantee communicate any evaluation findings to key stakeholders and/or key informants during this reporting period? (Select one response.)^{B, F}

Yes
No (If selected, you will automatically proceed to Question 172.)

170. How did you communicate the evaluation findings? (Select all that apply.)^{B, F}

Distributed written report to stakeholders
Presented findings at a meeting of stakeholders
Presented findings to community members/participants
Written press release
Televised press conference
Posted on website
Other (Describe.)__________________________________________________

171. Indicate how stakeholders used these evaluation findings. (Select all that apply.)^{B, F}

To modify prevention interventions
To set policy
To change substance abuse priorities
To leverage additional funds
To recruit additional partners
To leverage additional prevention staff
To encourage coordination among organizations or agencies
To learn/increase knowledge
Other (Describe.)__________________________________________________
Don’t know

Section 6: Systems Factors

For purposes of this instrument, the prevention system is “the entire set of agencies, organizations, and persons that contribute to efforts to prevent substance abuse and related problems within the community.” Keep this in mind as you answer the questions below about planning and data systems.

172. Does your community’s prevention system have a specific plan or vision/mission statement about substance abuse prevention that guides the community substance abuse prevention planning process? (Select one response.)^{B, F}

Yes
No
Don’t know

173. Does your community’s prevention system have a written, documented process for making substance abuse prevention-related decisions? (Select one response.)^{B, F}

Yes
No
Don’t know

174. Do multiple organizations and agencies in your community’s prevention system work together to collect, manage and organize community ATOD data? (Select one response.)^{B, F}

Yes
No
Don’t know

175. Is there a primary organization or agency in your community’s prevention system that has responsibility for management of the data? (Select one response.)^{B, F}

Yes
No
Don’t know

Section 7: Contextual Factors

Contextual factors are conditions that exist outside the scope of the prevention intervention activities, but nevertheless influence the SPF process and prevention intervention delivery. While you can incorporate knowledge of these factors into your planning and prevention interventions, they typically cannot be changed through intervention activities. Understanding the nature of contextual factors, however, is still helpful in evaluating the success of the prevention intervention.

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

Project Director
Project Coordinator
Intervention delivery staff
Evaluator
Coalition representative

176. We would like to learn about demographic, environmental, or cultural factors that may have introduced barriers and had an impact on prevention activities in your community during this reporting period. Which, if any, of the following factors may have had an impact on the outcomes of your prevention activities? (Select all that apply)^{B, F}

Cultural attitudes or practices conducive to high substance use
High poverty rates/low SES
Low literacy, lack of education, education a low priority, or high dropout rates
Large recent refugee/immigrant population
Easy access to alcohol (underage)
Easy access to illegal drugs
Lack of community awareness of the extent or consequences of substance abuse
Insufficient funds for prevention programs, lack of prevention/treatment programs
High unemployment or underemployment
Lack of transportation, difficulty reaching some parts of the community
Lack of resources in rural areas
Lack of trust in law enforcement/government/social services
Lack of law enforcement staff, laws/policies, poor enforcement of laws/policies
Lack of clear or conducive jurisdictional boundaries among different law enforcement agencies (i.e., city police, county sheriffs, tribal police)
Language barriers
Community disorganization
Lack of drug free activities for area youth, lack of supervision for area youth
Substance use related event(s) that got local media coverage and influenced public opinion
Stressful events affecting large portions of the target population, such as large fires, hurricanes, earthquakes, terrorism, etc.
Other (Describe.)

Section 8: Training or Technical Assistance

177. Select the areas in which you received SPF-SIG funded guidance, training or technical assistance during this reporting period. Do not include training that you are going to receive in the future. You will be able to report this in future reporting periods. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select all that apply.)^{B, F}

Not applicable—no training or technical assistance received
Cultural competence
Needs and resource assessment
Staff, task force, and/or coalition member training
Building relationships
Sustainability
Strategic plan development
Intervention selection
Participant Recruitment
Evaluation activities
Other (Describe.)_________________________________________________

Section 9: Closing Question

178. Do you have any additional comments about any aspects of the SPF SIG Initiative? (Provide a concise written description in the space available.) (3000 character limit.)^{B, F}

ATTACHMENT B1c: Page 1

File Type	application/msword
File Title	CLI Part 1 Revision
Author	DACCC
Last Modified By	Department of Health and Human Services
File Modified	2013-07-22
File Created	2013-07-22