ASSESSMENT SECTION

Status: Original and derived artifacts are available for this document.

Download: doc | pdf | html











Attachment 6:
Proposed Changes to Drug-Free Communities Progress Report


Proposed Changes to:
Drug-Free Communities Progress Report





Summary of proposed changes:
    1) Option for grantees to enter SPF-SIG and STOP Act grant number (if applicable) to Grantee/Coalition Information section.
    2) Option for “Lesbian/Gay/Bisexual/Transgender (LGBT) Youth” added to Community Settings List in the Needs Assessment section.
    3) Added 3 new items to Member Capacity Section regarding youth coalitions
        a. Indicate if have a youth coalition
        b. If yes, select from drop down menu how often meet
        c. If yes, select from drop down menu how involved in planning activities
    4) 3 new items added to Implementation Summary section.
        a. Describe policy/laws changed
        b. Select month and year from drop down menus
        c. Select Targeted Substance(s) from drop down menu
    5) 2 new items added to Community and Population-Level Outcomes section.
        a. Option of reporting outcome data by school level (i.e., Middle School or High School) instead of individual grade level, ONLY if not able to report by grade level
	

COALITION STRUCTURE AND PROCESSES SECTION
(Note: The first time you enter the progress reporting system, all sections will be blank. If you are a continuing grantee 
who has previously entered data, you will be able to get a report that provides all previously submitted data. After 
you enter data for the first time, all sections will be prefilled. You will be prompted to check the information and 
select to edit it if any prior submitted data has changed.)
Proposed Change
(if Any)
Date Updated: ___ /____

Grantee/Coalition Information
Grantee Name: _______________________	Award Number: ____________________
Coalition Name: _______________________
Year of First DFC Award: _______	Month and year your coalition was first established:  ___/___ 
If your coalition a SPF/SIG subrecipient? 	Is your coalition a STOP Act grantee? (pre-filled)
      
    • Yes (if Y	 Yes
    • No	 No
CHANGE: Replace items on SPF-SIG and STOP Act as follows.
If your coalition is a SPF/SIG subrecipient, please enter your grant number.
    • Our coalition is not a SPF/SIG subrecipient
    • Our SPF/SIG subrecipient grant number is ____________

If your coalition is a STOP Act grantee, please enter your grant number.
    • Our coalition is not a STOP Act grantee
    • Our STOP Act grantee grant number is ____________

Total number of members participating in your coalition:____________ 
(Note:  This number should include all members plus all staff.)
Number of paid staff: _________
Number of volunteer staff: ________
No Changes
Coalition Director Contact Information:
Name: ____________________________________
Title: _____________________________________
Address: __________________________________
___________________________________
Phone: ____________________________________
Fax: ______________________________________
Email: ____________________________________
Month and year coalition director took current position: ____/_____
Did your coalition director change during this reporting period? 
    • Yes 
    • No
If yes, please provide the month and year your previous coalition leader left the position: ____/_____
No Changes
Does your coalition serve a federally-recognized Tribal area? 
    • Yes 
    • No
Is your coalition headed by a religious or faith-based organization?
    • Yes
    • No
Does your coalition have at least one (1) representative from the Bureau of Indian Affairs, the Indian Health Service, or a Tribal Government Agency with expertise in the field of substance abuse? 
    • Yes
    • No
No Changes
Please provide a brief summary of your coalition. This is your “Elevator Speech.” There should be about one sentence describing each of the following (a) your community and target population, (b) your primary goals, (c) the activities you are focusing on, (d) accomplishments to date,  (e) successes concerning goal achievement, f) challenges in goal achievement, and g) things that make your coalition unique. 
No Changes

Needs Assessment
Needs Assessment refers to the decisions your coalition has made concerning the major problems upon which you want to focus, the major community areas and populations you want to serve, and the reasons that these priorities were established. In addition, needs assessment refers to the ways you have collected data, or assessed the communities concern, to establish these priorities.
Geographic setting(s) served (check all that apply):
    • Inner City 
    • Urban 
    • Suburban
    • Rural
    • Frontier
Community setting(s) served (check all that apply):
No Changes

      
    • Single School District
    • Multiple School Districts
    • Single School
    • Multiple Schools

    • City
    • Multiple Cities
    • Town
    • Multiple Towns

    • Neighborhood
    • Multiple Neighborhoods
    • County
    • Region or Other Subsection of a State
    • Native American/American Indian/Alaskan Native Reservation
    • Military
    • Colleges & Universities 


Do you target information/intervention efforts to a specific minority group or minority groups?
    • Yes 
    • No
If yes, please specify (check all that apply):
    • American Indian or Alaska Native
    • Asian
    • Black or African-American
    • Hispanic or Latino
    • Native Hawaiian or Other Pacific Islander
    • Lesbian/Gay/Bisexual/Transgender (LGBT) Youth
CHANGE: Add Lesbian/Gay/Bisexual/
Transgender (LGBT) Youth to Community Settings List
Grade level(s) served (check all that apply):

    • Elementary school (K-5)

    • 6th grade
    • 7th grade
    • 8th grade
    • 9th grade
    • 10th grade
    • 11th grade
    • 12th grade
    • 
No Changes
Please select up to five (5) substances that your coalition is targeting in your community:

    • Alcohol 
    • Tobacco 
    • Marijuana 
    • Prescription Drugs 
    • Cocaine/Crack
    • Heroin
    • Stimulants (uppers)
    • Tranquilizers
    • Hallucinogens
    • Over-the-counter (OTC) drugs 
    • Inhalants 
    • Steroids 
    • Synthetic Drugs/Emerging Drugs
    • Additional substances addressed: __________ 
No Changes
Target Zip Codes
(Note:  This section will be prefilled unless you have not entered data previously.  You will be prompted to check the information and select to edit it if any prior submitted data has changed. You may also upload zip codes, but in order to do so, you MUST use the provided EXCEL file template.)

Zip Code Served
Do you serve the entire zip code? 
(Dropdown: Yes/No)
If no, please list the specific areas served (e.g., names of neighborhoods, school districts, etc.)
No Changes












Program Budget 
(Note:  This section will be prefilled unless you have not entered data previously.  You will be prompted to check the information and select to edit it if any prior submitted data has changed.)
Prompted with: Has the information below changed from what was reported in previous reporting period? 
    • Yes*
    • No (skip to next section  - “Member Capacity”)
What is your coalition's current total annual operating budget?  $ _______________
Please specify the period that this budget covers: From: mm/dd/yyyy   To: mm/dd/yyyy
No Changes
What dollar amount of your total operating budget comes from each of the following funding sources?
Source of Funding/Resources 
Dollar Amount
(Note: Be sure the amounts below total to the amount submitted as your current total annual operating budget provided above.)
Percentage
(Note: The system will automatically calculate percentages for you. You will not enter this data.)
No Changes
DFC grant



STOP Act grant



SPF-SIG funding



Other federal government funding



Other state government funding



Other local government funding



Foundation/Non-profit organizations



Private/Corporate entities



Individual donations/Funding from fundraising events



In-Kind contributions



Other (if applicable, please specify up to one other funding source) _____________________



In the next 12 months do you expect your coalition's funding level to:
    • Increase
    • Decrease
    • Stay about the same
No Changes
Comments (NOTE: Provide any information relevant to understanding your expectations regarding your coalition’s funding level. Please note funding uncertainties, opportunities, or other information relevant for understanding your coalition’s future funding.): _______
No Changes



MEMBER CAPACITY SECTION
Capacity refers to the types (such as skills or technology) and levels (such as individual or organizational) of resources that a coalition has at its disposal to meet its aims.
Proposed Change
(if Any)
Membership
(Note:  This section will be prefilled unless you have not entered data previously.  You will be prompted to check the information and select to edit it if any prior submitted data has changed.)
Number of formal coalition meetings held during this period: ___
Average attendance at coalition meetings 
(not including paid staff): ___
Is collaboration among members of your coalition (NOTE: Think about the level of participation in coalition decisions, participation in joint activities, and other collaborative interactions in your prior reporting period relative to now.):
    • Increasing
    • Decreasing
    • Staying the same

No Changes
Sectors
How many coalition members represent this sector?
*Note: Enter a number. If a member represents more than one sector please only count them once, under the sector that represents him/her best. For example you may have a police officer who is also a parent, but if they are there because on police force then indicate as law enforcement, not as parent.
How many of these coalition members are “active” (i.e., have attended at least one meeting in the past six months)?
What is the average level of involvement 
for each of the sectors?
No Changes



Very High
High
Medium
Some
Low

Parents








Youth








Business Community








Civic/Volunteer Groups








Healthcare Professionals








Law Enforcement agency








Media








Religious/Fraternal organizations








Schools








State, local, and/or tribal government agencies








Youth-serving organizations








Other Organization with Expertise in Substance Abuse (please specify up to one additional sector) ___________________








Member Roster
(Note: The Center for Substance Abuse Prevention (CSAP) requests that you enter a roster of all individuals and organizations involved in your coalition. You may also upload a member roster, but in order to do so, you MUST use the provided EXCEL file template.)
First Name
(Note: If entering an organization enter organization name in last name and leave first name blank.)
Last Name
(Note: If entering an organization enter organization name in last name and leave first name blank.)
Type
(Note:  You will select either individual or organization from drop down list.)
Sector
(Note: Select from drop down: list of sectors. If you select “other” you will be asked to specify.)
Status
(Note: Select from drop down menu if individual/organization is an active or inactive member of the coalition.)
No Changes
Note:  You will be able to enter as many members as needed.




No Changes
What is being done to increase membership in the sectors not represented?  (Note: This information is only requested if you do not list at least one member representing each sector.) 
No Changes
Capacity Building Activities
Capacity building activities include any efforts explicitly designed to improve the ability of the coalition to successfully assess needs, plan, make decisions, implement effective activities, evaluate, improve, and sustain coalition functioning.
Please select up to three (3) capacity building activities that were the main focus of your coalition’s efforts during the last reporting period:

    • Gathering community input (e.g., holding hearings on drug problems)
    • Recruitment (e.g., increasing coalition membership and participation)
    • Training for coalition members (e.g., building leadership capacity among coalition members)
    • Building shared vision/consensus (e.g., attaining an agreement among coalition members regarding goals, planned initiatives, etc.)
    • Increasing fiscal resources (e.g., attaining funding for substance abuse prevention initiatives)
    • Strengthening interventions (e.g., planning/executing substance abuse prevention initiatives)
    • Outreach (e.g., engaging key stakeholders in substance abuse prevention initiatives)
    • Engaging the general community in substance abuse prevention initiatives
    • Developing/Executing a media plan to draw attention to new drug threats
    • Improving information resources (e.g., engaging in research or evaluation activities)
    • Other ( please specify ): _____________________
    • None

No Changes
Does your coalition have a youth coalition that meets separately?
    • Yes 
    • No
If yes, how often did the youth coalition meet over the last six months?
    • Every 1-2 weeks
    • Once a month
    • Once every two months
    • One to two times in the past six months
What is the average level of involvement of the youth coalition in planning prevention activities with youth?
    • Very High
    • High
    • Medium
    • Some
    • Low

New Items
Please report any notable accomplishments related to capacity building activities achieved during this reporting period:
No Changes
Please report any additional details, including barriers or challenges, about your capacity building activities that were not captured above, but are relevant to understanding your coalition’s activities/outcomes: 
No Changes



COALITION PROCESSES SECTION
Proposed Change 
(if Any)
Challenges and Protective Assets
Challenges or risk factors are characteristics of community, individuals, families, schools or other circumstances that increase the likelihood or difficulty of mitigating substance use and its associated harms. Prevention activities often focus on reducing risk factors that are perceived to be particularly important in a community.
What are the primary challenges that you face in your community? (Note: Select all that apply)
No Changes
Community Factors
    • Inadequate laws/ ordinances related to substance use/access

    • Inadequate enforcement of laws/ordinances related to substance use

    • Availability of substances that can be abused

    • Perceived acceptability (or disapproval) of substance abuse

Individual Factors
    • Favorable attitudes towards the problem behavior

    • Early initiation of the problem behavior

Family Factors
    • Family trauma/stress

    • Parental attitudes favorable to antisocial behavior

    • Parents lack ability/ confidence to speak to their children about ATOD use

School Factors
    • Academic failure 

    • Low commitment to school

Other
    • Coalition can enter free-form text

Protective Factors
Protective factors are characteristics of a community, individuals, families, schools or other circumstances that decrease the likelihood of substance use and its associated harms. Prevention activities often focus on strengthening protective factors that are perceived to be particularly important in a community.
Select the major protective factors that your coalition is targeting. (Note: Select all that apply. When you select a factor, please answer the follow up question on trend data for that factor.)
No Changes
Community Factors
    • Laws, regulations, and policies

    • Strong community organization (e.g., less crime, less visible drug dealing)

    • Advertising and other promotion of information related to ATOD use 

    • Pro-social community involvement

    • Cultural awareness, sensitivity, and inclusiveness

Family Factors
    • Family economic resources

    • Parental monitoring and supervision

    • Family connectedness

    • Opportunities for pro-social family involvement

Individual Factors
    • Positive contributions to peer group

    • Recognition/acknowledgement of efforts

School Factors
    • Contributions to the school community

    • Positive school climate

    • School connectedness

Other
Coalition can enter free-form text

Please report any additional details about your challenges and protective assets that were not captured above:
No Changes
Assessment Activities
Assessment - The systematic gathering and analysis of data to identify current assets, problems, and related conditions that require intervention.
Please select up to three (3) assessment activities that were the main focus of your coalition’s efforts during the last reporting period:
    • Preparing to assess needs and capacity (e.g., identifying coalition goals)
    • Designing/selecting interventions
    • Collecting data for assessment purposes
    • Analyzing and reporting assessment data
    • Completing a SWOT ( strengths, weaknesses, opportunities, and threats) analysis
    • Developing a framework/logic model for change
    • Using assessment data (e.g., revising a logic model)
    • Other ( please specify ): _____________________
    • None
No Changes
Please report any notable accomplishments related to assessment activities achieved during this reporting period.:

No Changes
Please report any additional details, including barriers or challenges, about your assessment activities that were not captured above: 
No Changes


PLANNING SECTION
Planning is a process of developing a logical sequence of steps that lead from individual actions
to community-level drug outcomes and achievement of the coalition’s vision for a healthier community.
Proposed Change 
	(if Any)
Planning Activities 
NOTE:  Coalitions will be prompted to upload their strategic plan, logic model, and action plans. Anytime you change any of these documents, a new file should be uploaded.
Has your coalition made any modifications to your strategic plan during this reporting period?
    • Yes
    • No

If yes, please describe: _______________________________

Has your coalition made any modifications to your Logic Model during this reporting period?
    • Yes
    • No

If yes, please describe: _______________________________
Has your coalition developed a new action plan during this reporting period?
    • Yes
    • No
If yes, please describe: _____________________________
No Changes


      

Please report any notable accomplishments related to planning activities achieved during this reporting period:
_________________________________________________________________________________________________________
No Changes
 Please report any additional details, including barriers or challenges about your planning activities that were not captured above:___________________________________________________________________________________________________
No Changes
Summary of Effort: Coalition Processes
Approximately what percent of overall coalition effort went into each of the following processes? (Note: total should sum to 100%)
___% Assessment	___% Capacity	___% Planning	___% Implementation	___% Evaluation
No Changes
Approximately what percent of overall coalition resources went into each of the following processes? (Note:  total should sum to 100%)
___% Assessment	___% Capacity	___% Planning	___% Implementation	___% Evaluation
No Changes



IMPLEMENTATION SECTION
Implementation puts into motion the activities identified in the planning process. In this section, grantees will first rank their level of effort related to each of the seven strategies. Then, for each strategy, grantees will be asked to describe the types of activities engaged in during the reporting period.
Proposed Changes 
(if Any)
Implementation Strategies
Implementation Strategies

(These categories apply to both capacity building in the community [supporting programs to do these things] as well as direct actions)
Rank the implementation strategies by the amount of your coalition's paid staff labor effort that was spent on each:
Rank the implementation strategies by the amount of your coalition members’ labor effort that was spent on each:
Rank the implementation strategies by the amount of your coalition's budget that was spent on each:
No Changes
Providing Information (e.g., community education, increasing knowledge, raising awareness)
Drop down of ranks (1=Most Effort to 7=Least Effort), plus an Option for Not Applicable (no effort expended)
Drop down of ranks (1=Most Effort to 7=Least Effort), plus an Option for Not Applicable (no effort expended)
Drop down of ranks (1=Most Budget to 7=Least Budget), plus an Option for Not Applicable (no money expended)

Enhancing Skills (e.g., building skills and competencies)




Providing Support (e.g., increasing involvement in drug-free/healthy alternative activities)




Enhancing Access/Reducing Barriers (e.g., improving access, availability, and use of systems and service)




Changing Consequences (e.g., incentives/disincentives, increasing attention to enforcement and compliance)




Physical Design (e.g., improving environmental and structural signs and areas to support the initiative)




Modifying/Changing Policies (e.g., changing institutional or government policies)




Strategy Activity Details:  Providing Information
Activities focused on providing information
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did Your coalition Use STOP Act funds to support the following new or advanced activities? (Note: Clicking on button will indicate yes, used STOP Act funds.)
Number of completed activities this period
Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
How many people did this activity reach?
Sector(s) Contributing to This Activity 
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; (2) moderately successful; (3) not successful
No Changes





Adults
Youth



Media campaigns: Television/Radio/Print/Billboards/Bus or other Posters
 Yes
 No

Number of spots/ ads aired or placed this reporting period

Not applicable for this activity
Not applicable for this activity


No Changes
Media coverage :  TV / radio / newspaper stories 
 Yes
 No

Number of  media stories appearing  this reporting period

Not applicable for this activity
Not applicable for this activity


No Changes
Informational materials prepared/ produced
 Yes
 No

Number of press releases, brochures, flyers, posters, audiovisual products prepared/ produced during this reporting period

Not applicable for this activity
Not applicable for this activity


No Changes
Informational materials disseminated 
 Yes
 No

Number of brochures, flyers, posters, audio visual products distributed during this reporting period





No Changes
Social networking (Facebook, Twitter, etc.)
 Yes
 No

Number of posts on social media sites during reporting period. 

Facebook "Friends"; Twitter "Followers” 
Facebook "Friends"; Twitter "Followers”


No Changes
Information on DFC Coalition Web site
 Yes
 No

Number of new materials posted during this reporting period.

Number of web hits (for this activity indicate total number of web hits in the number of adults column)
Not applicable for this activity


No Changes
Direct, face-to-face information sessions
 Yes
 No

Number of educational presentations, workshops, seminars, town hall meetings held during this reporting period by your coalition staff. Only include sessions intended to provide general information. Training sessions will be covered in the next topic.

Number of adults in audience
Number of youth in audience


No Changes
Special events  (e.g., fairs, community celebrations)
 Yes
 No

Number of events that your coalition participated in during this reporting period. These events could be either run by your coalition, or your coalition could participate in them.

Approximate adult attendance at events
Approximate youth attendance at events


No Changes
Other ( please specify ): (NOTE:  Grantee able to add multiple “other” activity rows)








No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving providing information: 
 Completely responsible for most activities
 Typically does not take lead, but helps coalition members
  Typically takes lead with help from coalition members
 Minimally involved: coalition members take on most responsibilities
No Changes
Strategy Activity Details: Enhancing Skills
Activities focused on enhancing skills
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did Your coalition Use STOP Act funds to support the following new or enhanced activities? (Note: Clicking on button will indicate yes, used STOP Act funds.)
Number of completed activities this period
Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
How many people did this activity reach?
Sector(s) Contributing to This Activity
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; (2) moderately successful; (3) not successful
No Changes





Adults
Youth



Youth Education and Training Programs (providing Information / skills)
    • Yes
    • No

Number of sessions delivered of programs focusing on information skills

Not applicable for this activity
Number of youth receiving training (do not double count if youth received more than one session)


No Changes
Parent Education and Training Programs 
    • Yes
    • No

Number of training sessions on drug awareness, prevention strategies, parenting skills specifically for parents

Number of parents receiving training (do not double count if parent received more than one session)
Not applicable for this activity


No Changes
Teacher/ Youth Worker Education and Training Programs
    • Yes
    • No

Number of training sessions on drug awareness and prevention strategies specifically for teachers / Youth Workers

Number of teachers / youth workers trained (do not double count if participant received more than one session)
Not applicable for this activity


No Changes
Community Member Education and Training Programs 
    • Yes
    • No

Number of training sessions on drug awareness and prevention strategies, cultural competence for community members, including law enforcement, media, and landlords

Number of community members trained (do not double count if community member received more than one session)
Not applicable for this activity


No Changes
Business Training (e.g., responsible beverage service/ vendor training [voluntary or mandatory])
    • Yes
    • No

Number of training sessions delivered on server compliance, training on youth marketed alcohol products, tobacco sales, etc.

Number of people trained (do not double count if participant received more than one session)
Not applicable for this activity


No Changes
Other ( please specify ): (NOTE:  Grantee will be able to add multiple other activity rows)
    • Yes
    • No







No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving enhancing skills: 
 Completely responsible for most activities
 Typically does not take lead, but helps coalition members
 Typically takes lead with help from coalition members
 Minimally involved: coalition members take on most responsibilities
No Changes
Strategy Activity Details: Providing Support
Activities focused on providing support
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did Your coalition Use STOP Act funds to support the following new or enhanced activities? (Note: Clicking on button will indicate yes, used STOP Act funds.)
Number of completed activities this period
Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
How many people did this activity reach?
Sector(s) Contributing to This Activity
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; (2) moderately successful; (3) not successful
No Changes





Adults
Youth



Alternative/drug-free social events 
    • Yes
    • No

Number of drug-free parties, other events supported by coalition

Number of attendees: Adults not part of coalition
Number of attendees: youth


No Changes
Youth organizations/ drop-in centers 
    • Yes
    • No

Number of clubs (after-school or other) and centers supported by your coalition. "Support" can be in the form of financial, labor, or in-kind assistance.


Number of youth belonging to clubs or centers


No Changes
Organized youth recreation programs (e.g., athletics, arts, outdoor activities)
    • Yes
    • No

Number of events supported by your coalition: please do not include events that are designed specifically to provide information


Number of league participants


No Changes
Youth/ family community involvement (e.g., school or neighborhood cleanup)
    • Yes
    • No

Number of community involvement events held

Number of adult participants
Number of youth participants


No Changes
Youth/family support groups
    • Yes
    • No

Number of groups (e.g., leadership groups, mentoring programs, youth employment programs)

Number of adult participants
Number of student participants, including number of mentoring matches (do not double count if youth received more than one session, or if the youth participated in mentoring plus other programs)


No Changes
Other ( please specify ): (NOTE:  Grantee will be able to add multiple other activity rows)
_____________
    • Yes
    • No







No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving providing support: 
 Completely responsible for most activities
 Typically takes the lead with help from coalition members
 Typically does not take lead, but helps coalition members
 Minimally involved: coalition members take on most responsibilities
No Changes
Strategy Activity Details: Enhancing Access/Reducing Barriers
Activities focused on enhancing access / reducing barriers
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did Your coalition Use STOP Act funds to support the following new or enhanced activities? (Note: Clicking on button will indicate yes, used STOP Act funds.)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
How many people did this activity reach?
Sector(s) Contributing to This Activity
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; (2) moderately successful; (3) not successful
No Changes




Adults
Youth



Increased Access to Substance Use Services (e.g., court mandated service, assessment and referral, EAP’s, SAP’s)
    • Yes
    • No


Number of adults served, referred to treatment, involved in EAPs
Number of youth served, referred to treatment, involved in SAPs


No Changes
Reducing Home and Social Access to Alcohol and Other Substances (e.g., prescription drug disposal)
    • Yes
    • No


Number of adults participating in prescription drug takeback programs
Number of youth participating in prescription drug takeback programs


No Changes
Improve supports for service use (e.g., transportation, child care)
    • Yes
    • No


Number of adults served
Number of youth served


No Changes
Improve access through culturally sensitive outreach (e.g., multilingual materials)
    • Yes
    • No


Number of adults targeted (this may be double-counted with your entries for “Providing Information”
Number of youth targeted (this may be double-counted with your entries for “Providing Information”


No Changes
Other (please specify): (NOTE:  Grantee will be able to add multiple other activity rows)
_____________
    • Yes
    • No






No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving enhancing access/reducing barriers: 
 Completely responsible for most activities
 Typically does not take lead, but helps coalition members
 Typically takes lead with help from coalition members
 Minimally involved: coalition members take on most responsibilities
No Changes
Strategy Activity Details: Changing Consequences
Activities focused on changing consequences
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did your coalition use STOP Act funds to support the following new or enhanced activities?
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
How Many Businesses Did Each Activity Reach? Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Sector(s) Contributing to This Activity
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; (2) moderately successful; (3) not successful
No Changes
Strengthening  Enforcement (e.g., supporting DUI checkpoints, shoulder tap programs, open container laws)
    • Yes
    • No

Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, Multiple/ Substances/No Substance Specified
Not applicable for this activity


No Changes
Strengthening Surveillance (e.g., “hot spots,” party patrols)
    • Yes
    • No


Not applicable for this activity


No Changes
Recognition programs (e.g., programs  for merchants who pass compliance checks, drug free youth)
    • Yes
    • No


Number of businesses receiving recognition for compliance


No Changes
Publicize Non-Compliance (e.g., advertisements highlighting businesses non-compliant with local ordinances)
    • Yes
    • No


Number of businesses receiving recognition for non-compliance


No Changes
Other (please specify ): (NOTE:  Grantee will be able to add multiple other activity rows)

    • Yes
    • No





No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving changing consequences: 
 Completely responsible for most activities
 Typically does not take lead, but helps coalition members 
  Typically takes lead with help from coalition members
 Minimally involved: coalition members take on most responsibilities
No Changes
Strategy Activity Detail: Physical Design
Activities focused on physical design
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did Your coalition Use STOP Act funds to support the following? (Note: Clicking on button will indicate yes, used STOP Act funds.)
Number of completed activities this period
Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances

Sector(s) Contributing to This Activity
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; 
(2) moderately successful; (3) not successful
No Changes
Identify Physical Design Problems (e.g., environmental scans, neighborhood meetings, windshield surveys)
    • Yes
    • No

Number of physical design problems (e.g., hot spots, clean up areas, outlet clusters) identified this period.



No Changes
Cleanup and Beautification (e.g., Improve parks and other physical landscapes, neighborhood clean-ups)
    • Yes
    • No

Number of cleanup / beautification events held this period (e.g., neighborhood cleanup days)



No Changes
Improve visibility/ ease of surveillance in public places and substance use hotspots (e.g., improved lighting, surveillance cameras, improved lines of sight)
    • Yes
    • No

Number of areas (public places / hot spots) in which surveillance / visibility was improved this period.



No Changes
Promote improved signage / advertising / practices by suppliers (e.g., Decrease signage/ advertising / change product locations)
    • Yes
    • No

Number of suppliers making changes in signage / advertising / displays this period.



No Changes
Identify problem establishments for closure (e.g., close drug houses)
    • Yes
    • No

Number of problem establishments identified / targeted; Number closed / modified practices



No Changes
Encourage business / supplier designation of “no alcohol” or “no tobacco” zones
    • Yes
    • No

Number of businesses targeted / approached;  number that made changes



No Changes
Other ( please specify ): (NOTE:  Grantee will be able to add multiple other activity rows)
_____________
    • Yes
    • No





No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving physical design: 
 Completely responsible for most activities
 Typically does not take lead, but helps coalition members
 Typically takes lead with help from coalition members
 Minimally involved: coalition members take on most responsibilities
No Changes


IMPLEMENTATION SECTION
Implementation puts into motion the activities identified in the planning process. In this section, grantees will first rank their level of effort related to each of the seven strategies. Then, for each strategy, grantees will be asked to describe the types of activities engaged in during the reporting period.
Proposed Changes 
(if Any)
Strategy Activity Detail: Modifying/Changing Policies
Activities focused on Modifying / Changing Policies
Did your coalition work on this activity during this reporting period?
(Note:  Grantee will only complete rest of row for activities they indicate yes they worked on.)
Visible Only to STOP ACT Grantees
Did Your coalition Use STOP Act funds to support the following new or enhanced activities? (Note: Clicking on button will indicate yes, used STOP Act funds.)
Number of Policies or Laws Promoted or Opposed by Your Coalition this Reporting Period
Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Number of Policies or Laws Passed/Modified During This Period (hover over cells for more information)
Grantee will fill in a number. Option to hover over cells for more information such as what is in cells below.)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
Sector(s) Contributing to This Activity
Drop down: list of sectors, includes option for N/A: Paid Staff/ Volunteer Accomplishment
In your opinion, how successful was this effort?
Drop down: (1) very successful; (2) moderately successful; (3) not successful
No Changes
Cost: Laws/public policies concerning cost ( e.g., alcohol or tobacco tax, fees) 
    • Yes
    • No

Number of laws or policies concerning cost incentives promoted or opposed during this reporting period
Number of laws passed or modified -- and policies initiated this period



No Changes
Underage Use: Laws/public policies targeting use, possession, or behavior under the influence for minors
    • Yes
    • No

Number of laws or public policies supported / promoted by DFC coalition concerning underage use, possession, or behavior under the influence (e.g., underage consumption, false identification laws, blood alcohol concentration, graduated driver’s licenses, loss of driving privileges for alcohol violations by minors)
Number of laws passed or modified this period concerning underage use, possession, or behavior under the influence (e.g., underage consumption, false identification laws, blood alcohol concentration, graduated driver’s licenses, loss of driving privileges for alcohol violations by minors)



No Changes
School: Policies promoting drug-free schools
    • Yes
    • No

Number of laws or policies concerning drug-free schools promoted / supported by DFC coalition this period. Do not include policies focused on underage use/possession that were covered above.
Number of laws or policies concerning drug-free schools passed or modified during this period. Do not include policies focused on underage use/possession that were covered above



No Changes
Treatment/ Prevention: Laws/ public policies promoting treatment or prevention alternatives (e.g., diversion treatment programs for underage substance use offenders)
    • Yes
    • No

Number of laws or public policies concerning availability and sentencing alternatives to increase treatment / prevention promoted / supported by DFC coalition this period.
Number of laws/ policies passed or modified this period concerning availability and sentencing alternatives to increase treatment / prevention  



No Changes
Workplace: Policies promoting drug-free workplaces 
    • Yes
    • No

Number of laws or policies concerning drug-free workplaces promoted / supported by DFC coalition this period. Do not include policies mandating treatment.
Number of laws or policies concerning drug-free workplaces passed or modified during this period. Do not include policies mandating treatment.



No Changes
Citizen enabling/Liability: Laws/ public policies concerning adult (including parent) social enabling or liability (e.g., social host ordinances)
    • Yes
    • No

Number of laws or public policies concerning adult/parent social enabling or liability promoted/ supported by DFC coalition this period.
Number of laws passed or modified this period concerning parent/ social enabling /liability.



No Changes
Supplier Promotion / Liability:  Laws/ public policies  concerning supplier  advertising, promotion, liability, (e.g. server liability,   product placement, happy hours, drink specials, mandatory compliance checks, responsible beverage service)
    • Yes
    • No

Number of laws or public policies concerning supplier advertising, promotion, or liability promoted/supported by DFC coalition this period.
Number of laws passed or modified this period concerning supplier advertising, promotion, liability.



No Changes
Outlet Location / Density: Laws/ public policies concerning limitation and restrictions of location and density of alcohol outlets
    • Yes
    • No

Number of laws or zoning ordinances concerning density/ location of alcohol outlets promoted / supported by DFC coalition this reporting period.
Number of laws/zoning ordinances passed this period concerning the density of alcohol outlets



No Changes
Sales Restrictions: Laws/ public policies concerning restrictions on product sales (e.g., methamphetamine pre-cursor access, alcohol at gas stations)
    • Yes
    • No

Number of laws or public policies concerning restrictions on product sales promoted/ supported by DFC coalition this period.
Number of laws/ public policies concerning restrictions on product sales passed or modified this period.



No Changes
Other ( please specify ): (NOTE:  Grantee will be able to add multiple other activity rows)
____________
    • Yes
    • No






No Changes
Indicate the average level of contribution that coalition paid/volunteer staff made to activities involving modifying/changing policies: 
 Completely responsible for most activities
 Typically does not take lead, but helps coalition members
 Typically takes lead with help from coalition members 
 Minimally involved: coalition members take on most responsibilities
No Changes
Implementation Summary 
In the last six months, did you coalition successfully modify/change any policies/laws?
    • Yes
    • No (will automatically send to next item

CHANGE: New Item
If yes, briefly describe the policy/law, indicate the month and year the work to successfully modify/change the policy was completed and select the substance(s) targeted by the policy.
Policy 1: ___(open text field)_______________________________
Month/Year (select from dropdown)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
Policy 2: _____________________________________________
Month/Year (select from dropdown)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances
Policy 3: _____________________________________________
Month/Year (select from dropdown)
Target Substance(s)
Drop down: Alcohol, Tobacco, Marijuana, Prescription Drugs, Other Substance, No Substance Specified; Grantees may select multiple substances

CHANGE: New Item. 
 Add dropdown menu for target of policy (e.g., alcohol regulation, marijuana)
Do you have any additional details, like accomplishments or challenges and barriers, related to implementation to report for this reporting period?

No Changes
Please report any notable accomplishments related to implementation activities achieved during this reporting period? 

No Changes
Please report any additional details, including barriers or challenges, about your implementation activities that were not captured above: 

No Changes



Coalition Evaluation Effort
Approximately what percent of your coalition’s evaluation effort and resources went into the following activities? 
(Total must add to 100%):
No Changes
___% Data collection
___% Data analysis
___% Identifying recommendations for improvement
___% Presenting evaluation findings
___% Other ( please specify ): _____________________




COMMUNITY AND POPULATION-LEVEL OUTCOMES
Proposed Changes 
(if Any)

Core Outcomes

Data Source (dropdown of coalition’s approved surveys)

No Changes

Outcome Category this Data Applies To (select 30- day use, perception of risk, perception of parental or perception of peer)
                                                                         **repeat this for every APPROVED core measure**
No Changes

Month and Year Data Were Collected:  __/__
No Changes

Compared to Target Area, the Geographical Area Covered by These Data Is:
    • Larger
    • Smaller
    • The Same
    • Don’t Know
Does your data represent your target population?
    • Yes
    • No
If no, please explain:______________
No Changes
No Changes

Core Measures
You must submit the survey used to collect the data that you are submitting in order to be able to submit core measure data. You will receive a survey review guide from the DFC National Evaluation team once their review of your survey is complete.  Be sure to leave adequate time prior to core measure data submission to complete this step in the process.  Surveys can be submitted at any time. Your survey review guide provides you with information on what data the grantee is expected to submit (which core measures have been approved for which substances) as well as guidance on how to calculate percentage use.

Grade
Measure
Alcohol
Tobacco
Marijuana
Prescription Drugs
No Changes

6
30-day Use




No Changes


Sample Size




No Changes

7
30-day Use




No Changes


Sample Size




No Changes

8
30-day Use




No Changes


Sample Size




No Changes

9
30-day Use




No Changes


Sample Size




No Changes

10
30-day Use




No Changes


Sample Size




No Changes

11
30-Day Use




No Changes


Sample Size




No Changes

12
30-Day Use




No Changes


Sample Size




No Changes

Middle School, multiple grades
30-Day Use




CHANGE: New Item. Add option of reporting outcome data by school level instead of grade level


Sample Size






High School,
Multiple grades
30-Day Use




CHANGE: New Item. Add option of reporting outcome data by school level instead of grade level


Sample Size






Male
30-Day Use




No Changes


Sample Size




No Changes

Female
30-Day Use




No Changes


Sample Size




No Changes

Are you collecting any other consequences? Optional section allows coalitions to enter their own core measures data on other substances. If you are collecting data particularly relative to change in substances other than the core substances, please share here.
No Changes

Outcomes Summary
Do you have any concerns about the quality of your data? Please explain.
    • Yes        No
         If yes, please explain:_______________________________
No Changes
Please report any notable accomplishments related to evaluation achieved during this reporting period:

No Changes
Please report any additional details, including barriers or challenges, about your evaluation activities that were not captured above 

No Changes


CHALLENGES AND TA
Proposed Changes 
(if Any)
Challenges
To what extent has your coalition experienced challenges in the following area?
Significant Challenge
4
Some Challenge
3
A Little Challenge
2
No Challenge
1
Not Applicable
0
No Changes
Increasing coalition membership and participation





No Changes
Building leadership capacity among coalition members





No Changes
Attaining an agreement among coalition members regarding goals, planned initiatives, etc.





No Changes
Developing/revising a framework/logic model of change  





No Changes
Completing a SWOT (strengths, weaknesses, opportunities, and threats) analysis





No Changes
Collecting/analyzing data for assessment purposes





No Changes
Recruiting/engaging target populations (e.g., students) in substance abuse prevention initiatives





No Changes
Engaging key stakeholders (e.g., school personnel) in substance abuse prevention initiatives





No Changes
Engaging the general community in substance abuse prevention initiatives





No Changes
Planning/Executing substance abuse prevention initiatives





No Changes
Developing/Executing a media plan to draw attention to new drug threats





No Changes
Attaining funding for substance abuse prevention initiatives





No Changes
Collecting/Analyzing data for evaluation purposes





No Changes
Other (please specify): __________________________





No Changes
Other (please specify): __________________________





No Changes
Other (please specify): __________________________





No Changes
Training and Technical Assistance: Survey of Needs
Training and technical assistance (T&TA) areas
To what extent would your coalition benefit from T&TA in each of these areas?
No Changes

A Great Deal
Some
A Little
Not at All
No Changes
Coalition and partnership development




No Changes
Coalition and partnership maintenance 




No Changes
Community needs and resource assessment 




No Changes
Goal and outcome development and assessment 




No Changes
Effective problem solving within a group setting




No Changes
Develop a framework or model of change




No Changes
Leadership development




No Changes
Cultural competency




No Changes
Organizational management 




No Changes
Strategic planning




No Changes
Developing substance abuse prevention initiatives




No Changes
Advocacy and policy development




No Changes
Grant writing




No Changes
Program evaluation




No Changes
Program/Initiative sustainability




No Changes
Other (please specify): __________________________




No Changes
Did your coalition provide any training or technical assistance to other community groups or organizations?
    • Yes
    • No
If yes, please describe:
No Changes