Form State collaboratio State collaboratio State collaboration indicator data instrument

OMB No 0930-XXXX

Expiration Date: XX/XX/XXXX

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-xxxx.  Public reporting burden for this collection of information is estimated to average 360 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.

Substance Abuse and Mental Health Services Administration

Multi-Site Evaluation of the Safe Schools Healthy Students State Program

State Collaboration Indicator Data Instrument Template

The data defined in this instrument will be directly entered by each grantee district into a secure online Safe Schools Healthy Students Evaluation Data System (SHEDS). The Multi-Site Evaluation team will work with local evaluators or grantees to ensure that the required indicators will be available. This document identifies the indicators that will be requested at the district level. Reporting will be quarterly. The Multi-Site Evaluation team will work with each state to agree on data collection processes to support this request, and identification of persons responsible for entering data into SHEDS each quarter.

Glossary:

• Project refers to the program primarily funded through the SS/HS State Program grant from the Substance Abuse and Mental Health Services Administration.

• Members include individual representatives and organizations that are on the State Management Team.

• Partners include all individuals who participate in program activities as part of the network of agencies, organizations, and individuals who are involved in SS/HS State Program work. It is the most inclusive network of contributors.

Reporting Period: MM/DD/YY – MM/DD/YY

State Management Team / Partnership

Meetings

Event	Activity this period?	# of Units	# Meetings	Total # of Members Attending	Total # of Non-member Participants	Total # of Attendees	Meeting Formats		Meeting Activities / Outputs
Data Type	Yes / No	#	#	#	#	#	Check up to 3	Response Options	Check up to 3	Response Codes
SMT Collaboration Meetings								Standing member-ship meeting Executive leader-ship meeting Standing committee Task work group Problem solving workgroup Other: Specify		Information sharing Review / approval Decision input Policy decision making Resource decision making Problem solving / recommendations Task design and implementation Other. Specify
SMT Meetings: Work Teams, Committees
Other Grantee Leadership Meetings
Other SS/HS State Partner Meetings

Member and Partner Involvement

	# Added this period by sectora					# Lost this period by sectora					# Contributingb resources this period by sectora					# Involvedb in state tasks this period by sectora					# Involvedb in district liaison work this period by sectora
	1	2	3	4	5	1	2	3	4	5
Data Type	Number					Number					Number					Number					Number
SMT Members
State Network Partners

a Sector Key: 1) Education, 2) Justice / Law Enforcement, 3) Mental / Behavioral Health, 4) Child / Family Services / Social Welfare, 5) Other

b Involved in activities/ contributions other than during meetings

State Program / Collaboration Activities

State SS/HS Website

	Feature on Site?	# Hits/ Views/ Questions c	# Downoads	# Events/ Added Items	# Participants	# Uploads / Submissions	Priority Target Audience(s)		Password Required ?
Data Type	Yes/ No	#	#	#	#	#	Check up to 3	Response Options	Yes/ No
State SS/HS Site Homepage								General public State members/ partners Sub-grantees (district, school) LEA members/ partners School staff School partners Sector workforce members Parents & youth Other specify
Calendar
Member / Partner List
Coalition News
Sub-grantee (District/ School) News
Features
Contact Us Online
Question Submission
TA/ Training Webinars
Materials: EBPs
Materials: Coalition Documents
Materials: Practice Information
Materials: Other
Resource List
Links
Coalition Monitoring / Performance
Online GPRA Data Entry
Other Online Data Entry
Other Feature (Specify:)

c If not applicable click NA/ If applicable but unknown leave blank

Guidance / Support for LEAs / Districts, Schools, and Communities

	Activity in your state?	Districts Served	Schools Served Directly	Community Orgs Served Directly	# of events / contacts	# of participants	Material / Training Content		SS/HS Sectors / Topics Addressed in Materials
Data Type	Yes/ No	#	#	#	#		√ all that apply	Response Options	√ all that apply	Response Options
Help line (phone/ e-mail)								SS/HS Framework SS/HS require-ments Other SS/HS materials Required programs Optional programs EBPs Collaborative practices Workforce skills Cultural competence Health disparity Evaluation / monitoring Other specify		Education: School climate Education: Disciplinary policy Education: Safety Education: Other Law enforcement: On-campus practices Law enforcement: Other Mental Health: Access/ disparity reduction Mental Health: EBPs Mental Health: Social / emotional development Early Childhood Services Substance use / violence prevention: EBPs Substance use / violence prevention: other Positive youth development Family, student, community, school collaboration Service integration Other
Social media messages (e.g., facebook, twitter)
Need Identification (input on helpful supports)
Program Materials (provided)
Program Information (Hard copies, or emailed)
Event Announcement / Invitations
State Conference(s)
Information Visits to Districts/ Schools
In-person Training (TOT)
In-person Training (Direct)
On-site TA
Remote TA
Administrative / monitoring visits to Districts/ Schools
Other specify

Member / Partner Contributions

# Partner agencies/ Organizations

Fiscal Resources (other than grant)

Designated employee(s)

Employee time as needed

Information Materials

Participation in committees / work groups

Participation in collaborative state projects

Participation in providing training / technical assistance

Communicating directly with local agencies/organizations in their sector

Providing assistance / support to local agencies / orgs

Changed policies to support SS/HS framework

Other specify

Sector Representation

Data Type

#

Yes /No

Yes/No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

√ all that apply

Response Options

Grantee Agency

Education Education: discipline, school safety School climate/ supportive schools Mental health Social / emotional development Child development Families & children Health Behavioral health/ prevention Behavioral health/ treatment Behavioral health/ violence prevention Law enforcement Judicial system Other

Member 1

Member 2

….

Member n

State Agency Partners

State private partners: public interest organizations

State private partners: non-profit providers

State private partners: businesses / associations

Expert partners: Universities / consultants

Other: Specify

4