Form Indirect Services Indirect Services Indirect Services Outcomes

OMB No. 0930-0xxx

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 0930-0XXX.  Public reporting burden for this collection of information is estimated to average 2 hours 0 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.

MAI Indirect Services Outcomes Reporting Tool

[Frequency: Completed once before the start of funded intervention implementation and then updated annually]

Grantee Name: ___________________________________

Grantee Award Number: ___________________________

Cohort: _________________________________________

Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

Instructions: This instrument is designed to collect data for evaluating the outcomes of indirect services implemented by MAI grantees. Since indirect services are population-based, that is, they are intended to benefit the entire community rather than being delivered to specific individuals, data for evaluating their outcomes needs to come from the community they are intended to benefit. There are two possible sources for community-level outcome data: (1) community surveys, and (2) event/surveillance data collected from the community for administrative or epidemiological surveillance purposes, such as records kept by the local police, hospitals, highway traffic agencies, school districts, or colleges.

1. Outcome Type (select only one)

• HIV

• Substance use

• Viral hepatitis

• Other (Specify) __________________________________

2. Data Source Type (select only one)

• Survey data

• Event/surveillance data

3. Data Timepoint

• Baseline

• Follow-up #1

• Follow-up #2

• Follow-up #3

• Follow-up #4

Instructions:

If “Survey data” is selected in #2 above, proceed to Section 1.

If “Event/surveillance data” is selected in #2 above, skip Section 1 and proceed to Section 2.

1. Survey Data

Instructions: Complete this section only if “Survey Data” was selected as Data Source Type.

1. Survey Data Source

1. Survey Data Source (select only one)

• American drug and alcohol survey

• Behavioral Risk Factor Surveillance System (BRFSS)

• Campus survey

• Communities that Care (CTC) youth survey

• Local/community survey

• National Survey on Drug Use and Health (NSDUH)

• School survey

• Search institute survey

• State survey

• PRIDE survey

• Youth Risk Behavior Surveillance System (YRBSS)

• Other (Specify) ____________________________

2. Data Collection Date |____|____| / |____|____|____|____|

Month Year

3. Measure: Source Item (indicate the item wording verbatim, exactly as it appears on the survey) __________________________________________

4. Measure: Response Options (indicate the response options, exactly as they appear on the survey) _____________________________________________________________

5. Data Source or Measure Comments ____________________________________________

2. Survey Population Information

1. Population from which Survey Sample is Drawn ______________________________________

2. Population Defined by Age Range or School/College Grade (select only one)

• Age Range

• School/College Grade

3. Survey Population Age Range Minimum (if “Age Range” is selected) ____________________

4. Survey Population Age Range Maximum (if “Age Range” is selected) ____________________

5. Survey Population School/College Grade (if “Grade” is selected; select all that apply)

• K

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10

• 11

• 12

• College Freshman

• College Sophomore

• College Junior

• College Senior

6. N of Population (enter the number of persons in the population from which the survey sample is drawn) ___________

7. Number of Survey Respondents (enter the number of persons who participated in the survey) __________

3. Outcome Information for Survey Data

1. Reported Outcome for Survey Data (provide a description of the specific outcome you are reporting for this measure, e.g. percent of college juniors and seniors who used alcohol in the past 30 days) ____________________________________________

2. Calculated Value (enter your actual numeric result for the outcome measure) _____________

3. Value Type (select only one)

• Mean

• Percentage

• Other (Specify) __________________________

2. Event/Surveillance Data

Instructions: Complete this section only if “Event/Surveillance Data” was selected as Data Source Type.

1. Event/Surveillance Data Source

1. Event/Surveillance Data Source (select only one)

• Campus health center

• Campus mental health center

• Campus security/police

• Community health center

• Community mental health center

• Fatality Analysis Reporting Systems (FARS)

• General college/university administrative records

• Hospital records

• Local/community agency reporting system

• State agency reporting system

• State/local police

• Uniform Crime Report (UCR)

• Other (Specify) ______________________________________

2. Data Source Time Frame Begin Date |____|____| / |____|____|____|____|

Month Year

3. Data Source Time Frame End Date |____|____| / |____|____|____|____|

Month Year

4. Measure: Event Definition ____________________________________________

5. Measure: Measure Calculation (provide a description of how you will be calculating the measure, specifying all elements of the equation including numerators, denominators, divisors, and multipliers) ____________________________________________

6. Data Source or Measure Comments ____________________________________________

2. Event/Surveillance Population Information

1. Population on which Event/Surveillance Data is Based (describe the population that the event data were designed to represent for this measure) _____________________________

2. Geographic unit of event (indicate what geographic level data are being reported; select only one)

• College/university campus

• Community

• School district

• County

• Town

• Metropolitan area

• State

• Tribe

• Other (Specify) ______________________________________________

3. Event/Surveillance Census Population Age Range Minimum ______

4. Event/Surveillance Census Population Age Range Maximum ______

5. N of Population for Event/Surveillance Data ______

3. Outcome Information for Event/Surveillance Data

1. Reported Outcome for Event/Surveillance Data (provide a description of the specific outcome you are reporting) _____________________________________

2. Number of Events (enter the number of times the event occurred) ______________

3. Denominator Definition (indicate how the reported outcome denominator is defined) ___________________________________________________

4. Denominator Value (indicate the numeric value of the denominator) ___________________

5. Calculated Value (enter your actual numeric result) _____________________

6. Value Type (select only one)

• Percentage

• Rate per 1,000

• Rate per 10,000

• Rate per 100,000

• Other (Specify) ___________________________________

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