Form Quarterly Progress Quarterly Progress Quarterly Progress Report

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 4 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 Quarterly Progress Report

Grantee Name: ___________________________________

Grantee Award Number: ___________________________

Cohort: _________________________________________

Reporting Period (quarter, federal fiscal year): __________

1. Health Disparities

[Frequency: Completed twice every federal fiscal year, as part of the second- and fourth-quarter progress reports]

In this section, we ask about your activities specifically aimed at serving health disparities subpopulations and through those services, reducing behavioral health disparities in your targeted community. The term "health disparities subpopulations” refers to specific demographic, language, age, socioeconomic status, sexual identity, or literacy groups that experience limited availability of or access to behavioral health services OR who experience worse substance use or HIV prevention outcomes compared to the general population.

1. Cultural Competence and Health Disparities Activities

1. Which of the following health disparities-related activities did your organization or institution conduct during this reporting period? (select all that apply)

• Conducted needs assessment activities specific to behavioral health disparities (e.g. identified subpopulations experiencing health disparities and their specific needs, collected data on identified subpopulations)

• Involved members of subpopulations experiencing health disparities in your CSAP/MAI activities, such as assessment, capacity building, planning, implementation, and evaluation

• Built organizational capacity for addressing health disparities (e.g. received trainings or built coalitions specifically for addressing disparities)

• Implemented strategies to address health disparities (e.g. interventions tailored to vulnerable subpopulations, efforts to increase access of vulnerable subpopulations to SA and HIV prevention and treatment services)

• Increased access to substance use and HIV prevention services for subpopulations experiencing health disparities (i.e., increased these populations' ability to get to or use these services). Increased access may refer to enhanced health coverage, services, timeliness, and workforce.

• Evaluated effects of implemented strategies on subpopulations experiencing health disparities

• Developed a plan to sustain progress made in addressing substance use and HIV-related health disparities beyond the CSAP/MAI grant

• Other (Specify) __________________________________________

2. Accomplishments and Barriers

1. what, if any, barriers are there to improving cultural competence in substance abuse and HIV prevention through your CSAP/MAI grant? (select all that apply and please include the date associated with accomplishments and barriers)

Date:

• Limited availability of culturally-specific evidence-based interventions for the target group(s)

• Need for staff that are of the same race or ethnicity as the target group(s)

• Need for staff training that is culturally-specific to the target group(s)

• Lack of commitment to cultural competence by partner organizations

• Competing priorities under the CSAP/MAI grant

• Other (Specify) ______________________________

• No barriers

1. During this reporting period, what, if any, specific accomplishments have you made toward the goal of improving cultural competence and/or addressing health disparities in substance abuse and HIV prevention through your CSAP/MAI grant? (E.g. Translated informational materials or surveys into the language of your vulnerable subpopulations, added members of vulnerable subpopulations to your Advisory Board, trained your staff in meeting the target population's diverse racial, ethnic, cultural, age, sex/gender orientation, and disability challenges):

3. Conclusions and Recommendations

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ____________________________________

2. Assessment

[Frequency: Completed at least once during the Assessment phase and updated quarterly, as needed]

Assessment involves the systematic gathering and examination of data about alcohol and drug problems, related conditions and consequences in the area of concern to the community prevention planning group. Assessing the problems means pinpointing where the problems are in the community and the populations that are impacted. It also means examining the conditions within the community that put it at risk for the problems and identifying conditions that now or in the future could protect against the problems.

1. Community Needs Assessment Synopsis Information

1. Date Approved |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Target Community or Institution Name ____________________________________

3. Target Geographical Area (select all that apply)

• Large urban area (population of more than 500,000)

• Smaller urban area (population of 50,000 to 500,000)

• Small town or urban cluster (population or 2,500 to 50,000)

• Rural

• Tribal Area

• Campus

• Other (Specify) __________________________________

4. Target Gender (select all that apply)

• Male

• Female

• Transgender

5. Target Ethnicity (select all that apply)

• Hispanic or Latino

• Not Hispanic or Latino

6. Target Race (select all that apply)

• American Indian/Alaska Native (AI/AN)

• Asian

• Black/African American

• Native Hawaiian or Other Pacific Islander

• White

7. Target Sexual Orientation (select all that apply)

• Straight or Heterosexual

• Bisexual

• Gay or Lesbian

• Unsure

8. Target Age Group (select all that apply)

• 12-15

• 16-17

• 18-20

• 21-24

• 25-29

• 30-39

• 40-49

• 50-59

• 60-69

• 70+

9. Target Population(s) (select all that apply)

• Adolescents (Age 12-17)

• Young Adults (Age 18-24) in college

• Young Adults (Age 18-24) not in college

• Older Adults (Age 50 and Over)

• American Indian/Alaska Natives (AI/AN)

• Asian American/Pacific Islanders

• Black/African American Women

• Black/African American Men

• Latina or Hispanic Women

• Latino or Hispanic Men

• Men Having Sex with Men (MSM)

• LGBTQ

• Military/Veterans

• Reentry Populations

• Homeless

• Sex Workers

• Low Income

• Other(s) (Specify) ___________________________________

10. Target Zip Codes ____________________________________________________

11. Description of Needs, Resources, Gaps _______________________________________

12. Findings of Epi Data __________________________________________________

13. Target Risk Factors/Target Protective Factors: (select all that apply)

• Attitudes supporting heavy alcohol use

• Attitudes supporting illicit drug use

• Attitudes supporting risky sexual behaviors

• Perceived risk of harm from unprotected sex

• Perceived risk of harm from heavy alcohol use

• Perceived risk of harm from illicit drug use

• Access to health services

• Awareness of health services

• Easy access to alcohol

• Positive alcohol expectancies

• Easy access to drugs

• Victimization

• Poor mental health

• Criminal justice involvement

• Experience with discrimination

• Life stress

• Early initiation of alcohol use

• Early initiation of drug use

• Injection drug use

• High knowledge of HIV

• Sexual self-efficacy

• High access to condoms or other forms of protection

• High social support

• Family connectedness

• Involvement with prosocial peer groups

• Positive intimate partner relationship

• Other(s) (Specify) __________________________

14. Targeted Capacity Expansion Type (select all that apply)

• Determining need based on data

• Developing prevention workforce

• Logically planning prevention services to address needs

• Providing evidence-based prevention services

• Evaluating prevention services delivered

15. Anticipated Impact of Targeted Capacity Expansion Type(s) on Organization’s Capacity (this item is optional) ________________________________________________

16. Upload/Attach your Needs Assessment Report

2. Community Needs Assessment Changes and Updates

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Change/Update Name ___________________________________

3. Description ____________________________________________

3. Accomplishments and Barriers

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one and please include the date associated with the accomplishments and barriers)

Date:

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name _________________________________________

3. Description ________________________________________________

4. Conclusions and Recommendations

[Optional]

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/Recommendation Name __________________________________________

3. Description of Conclusion/Recommendation ____________________________________

3. Capacity

[Frequency: Completed at least once during the Capacity Building phase and updated quarterly, as needed]

Capacity refers to the various types and levels of resources available to establish and maintain a sustainable community prevention system that can identify and leverage resources. Capacity to carry out prevention strategies depends not only upon the resources of the community organizations and their function as a cohesive problem-solving group, but also upon the readiness and ability of the larger community to commit its resources to addressing the identified problems.

1. Project, Organization/Institution, and Community Capacity

Staff Roster

Name	Date Joined	Position Title	FTE (Actual)	FTE (Approved)	Status	Date Exited (If Status is “Inactive”)
___________	Month|____|____| Day |____|____| Year|____|____|____|____	_______	__ __ %	__ __ %	Active Inactive	Month|____|____| Day |____|____| Year|____|____|____|____

Advisory Group and Governing Board Roster

Name	Date Joined	Affiliation	Member Type	Group Type	Status	Date Exited (If Status is “Inactive”)
___________	Month|____|____| Day |____|____| Year|____|____|____|____	________	Community Stakeholder Consumer	Project Advisory Group Governing Board	Active Inactive	Month|____|____| Day |____|____| Year|____|____|____|____

Collaborator Roster

Name	Date Joined	Collaborator Type	Gov’t Type (If Collaborator type is Government)	Organization Scope (If Collaborator type is Nongovernment)	Status	Date Exited (If Status is “Inactive”)
_________	Month|___|___| Day |___|___| Year|__|__|__|__	Government Nongovernment	Federal State Local	National Statewide Local	Active Inactive	Month|__|__| Day |__|__| Year|__|__|__|__

2. Project Advisory Council Meetings

1. Meeting Date|____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Meeting Name/Topic ______________________________________________

3. Upload/Attach agenda

4. Upload/Attach meeting minutes

5. Attendees: _______________________________________________________

________________________________________________________________

________________________________________________________________

3. Training and Technical Assistance (T/TA)

Instructions: Complete all items in this section separately for each T/TA event.

1. Date Requested|____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Status (select only one)

• Needed, not yet requested

• Requested

• Received

• Closed

3. Date Closed (completed If ‘Closed’ is selected for Status)

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

4. Training/TA Topic (select all that apply)

• Assessment

• Capacity

• Planning

• Implementation

• Evaluation

• Participatory Involvement

• Cultural Competence

• Sustainability

• Continuous Quality Improvement

• Other (Specify) __________________________________________

5. Select the option that best describes the delivery mechanism (select only one)

• Distance learning

• Technical assistance by telephone

• On-site/in-person technical assistance

• Technical assistance by email

• In-person class

• Conference or workshop

• Teleconference or telephone-based training

• Written materials

6. Select the option that best describes the source of assistance (select only one)

• CAPT

• CSAP Project Officer

• PEP-C

• SAMHSA Behavioral Health HIV Technical Assistance Center (AHP)

• State Prevention Organization

• Other (Specify) _____________________________________________

7. Was the Training/TA provided in a timely and effective manner (select only one)

• Yes

• No (please explain) _____________________________________

8. Description __________________________________________________________

4. Accomplishments and Barriers

4. Type (fill out this section separately for each additional accomplishment or barrier; select only one and please include the date associated with the accomplishments and barriers)

Date:

• Accomplishment

• Barrier

1. Accomplishment/Barrier Name _________________________________________

2. Description ________________________________________________

5. Conclusions and Recommendations

[Optional]

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

4. Planning

[Frequency: Completed at least once during the Planning phase and updated quarterly, as needed]

Planning involves following logical sequential steps designed to produce specific results. The desired results (Outcomes) are based upon data obtained from a formal assessment of needs and resources. The plan, then, outlines what will be done over time to create the desired change.

1. Strategic Prevention Plan Synopsis

1. Date Approved |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Over the life of the grant, estimate the total number of people you plan to serve through direct-service interventions: ________

3. Over the life of the grant, estimate the number of people you plan to serve through direct-service interventions by target population (Enter the number planned to serve by target population in the second column below; note, the number planned to serve for any given target population should not exceed the total planned to serve entered above in item 4.1.2):

Target Population	Number Planned to Serve
Adolescents (Age 12-17)
Young Adults (Age 18-24) in college
Young Adults (Age 18-24) not in college
Older Adults (Age 50 and Over)
American Indian/Alaska Natives
Asian American/Pacific Islanders
Black/African American Women
Black/African American Men
Latina or Hispanic Women
Latino or Hispanic Men
Men Having Sex with Men (MSM)
LGBTQ
Military/Veterans
Reentry Populations
Homeless
Sex Workers
Low Income
Other

(Number planned to serve for any given target population cannot exceed the total planned to serve through direct service interventions)

4. Workplan/Timeline Description _________________________________________________

5. Explain how substance abuse and HIV prevention services will be integrated: ______________

6. Upload/Attach your Strategic Plan

2. Goals, Objectives, and Outcome Categories

1. Targeted Goal(s) (select all that apply)

• Increase capacity to provide substance abuse, HIV, or viral hepatitis prevention services

• Prevent, slow the progress, and reduce the negative consequences of substance abuse

• Prevent, slow the progress, and reduce the negative consequences of HIV or viral hepatitis transmission

• Reduce health disparities in the community

Instructions: For each goal that you are targeting, complete the objectives roster, select outcome categories, and outcome measures. For goals that you are not targeting, leave the objectives and outcomes blank.

Goal: Increase capacity to provide substance abuse, HIV, or viral hepatitis prevention services

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ____________________ Objective Description: ____________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Goal: Prevent, slow the progress, and reduce the negative consequences of substance abuse

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ___________________ Objective Description: ____________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Outcome Category (select one or more)

• Perception of risk of harm from substance abuse (participant level)

• Disapproval of substance abuse (participant level)

• Other substance abuse risk/protective factors (participant level)

• Past-30 day substance use (participant level)

• Consequences of substance abuse (participant level)

• Substance abuse related community-level outcomes

Goal: Prevent, slow the progress, and reduce the negative consequences of HIV or viral hepatitis Transmission

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ___________________ Objective Description: ___________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Outcome Category (select one or more)

• HIV Knowledge, beliefs, and attitudes (participant level)

• Risky sexual behaviors (participant level)

• Other HIV or viral hepatitis risk/protective factors (participant level)

• HIV or viral hepatitis related community-level outcomes

Goal: Reduce health disparities in the community

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ___________________ Objective Description: ___________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Outcome Category (select one or more)

• Access to services (participant level)

• Community-level measures of health disparities

3. Targeted Outcome Measures

Instructions: Select the specific outcome measures your program will use to assess its success for each of the Outcome Categories selected above. Select all that apply.

Perception of risk of harm from substance abuse (participant level)

• Perceived risk of harm from alcohol use

• Perceived risk of harm from marijuana use

Disapproval of substance abuse (participant level)

• Disapproval of peer alcohol use (youth questionnaire only)

• Disapproval of peer alcohol use

• Disapproval of peer marijuana use (youth questionnaire only)

• Perceived peer disapproval of alcohol use

Other substance abuse related risk/protective factors (participant level)

• Intentions to use substances

• Belief that most peers binge drink

• Early initiation of substance use

• Drug refusal skills (youth questionnaire only)

• Strength of ties to ethnic community (youth questionnaire only)

• Social support for substance use issues (adult questionnaire only)

• Family cohesion

• Identification with ethnic group (youth questionnaire only)

• Homelessness

• Mental health status

Past 30-day substance use (participant level)

• Alcohol use

• Binge drinking

• Marijuana use

• Injectable drug use

• Nonmedical use of prescription drugs

• Illicit drug use other than marijuana, injectables, and prescription drug misuse

Consequences of substance abuse (participant level)

• Driving under the influence of alcohol or drugs

• Victim of unwanted sex while under the influence of alcohol or drugs

• Emotional problems due to substance use

• Stress due to substance abuse

Substance abuse related community-level outcomes

• Prevalence of alcohol use

• Prevalence of binge drinking

• Prevalence of marijuana use

• Prevalence of injectable drug use

• Percent who perceive risk of harm from binge drinking

• Percent who perceive risk of harm from marijuana use

• Percent who perceive risk of harm from substances other than alcohol and marijuana

• Percent who disapprove of binge drinking

• Percent who think their peers would disapprove of their binge drinking

• Percent who believe that most of their peers binge drink

• Alcohol/drug related traffic crashes or fatalities

• Other (Specify) _______________________________

HIV Knowledge, beliefs, and attitudes (participant level)

• Perceived risk of sharing non-sanitized needles (adult questionnaire only)

• Perception of risk of harm from unprotected sex

• Perceived risk of harm from risky sexual behavior (adult questionnaire only)

• Disapproval of peers engaging in unprotected sex

• Perceived peer disapproval of unprotected sex

• Belief that most peers engage in unprotected sex

• Intention to engage in risky sexual behaviors (next 3 months)

Risky sexual behaviors (participant level)

• Sex under the influence of drugs or alcohol

• Unprotected sex

• Number of sexual partners

• Exchanging sex for drugs, money, or shelter

Other HIV or viral hepatitis risk/protective factors (participant level)

• Sexual self-efficacy

• Social support for sexual issues (adult questionnaire only)

• Family cohesion

• Level of relationship abuse (adult questionnaire only)

• Identification with ethnic group (youth questionnaire only)

• Homelessness

• Mental health status

HIV or viral hepatitis related community-level outcomes

• Prevalence of HIV

• Prevalence of viral hepatitis

• Prevalence of STDs other than HIV and viral hepatitis

• Prevalence of sexual violence

• Percent who disapprove of unprotected sex

• Percent who believe that their peers would disapprove of unprotected sex

• Percent who believe that most of their peers engage in unprotected sex

• Percent who perceive risk of harm from unprotected sex

• Percent who disapprove of sex under the influence of drugs or alcohol

Access to services (participant level)

• Knowledge of sources of health information (adult questionnaire only)

• Knowledge of where to access services (adult questionnaire only)

• Difficulty accessing health services

• Perceived discrimination in accessing health services

• Health coverage

Community-level measures of health disparities

• Prevalence of HIV among identified vulnerable population(s)

• Prevalence of viral hepatitis among identified vulnerable population(s)

• Prevalence of alcohol use among identified vulnerable population(s)

• Prevalence of binge drinking among identified vulnerable population(s)

• Prevalence of marijuana use among identified vulnerable population(s)

• Prevalence of injectable drug use among identified vulnerable population(s)

• Other(s) (Specify) ___________________________________

4. Direct-Service Intervention Planning

Instructions: Complete all items in this section separately for each direct-service intervention you are planning. In this context, “intervention,” refers to an activity or a set of coordinated activities to which a group or individual is exposed to in order to change their behavior or their knowledge/attitudes associated with behavior change.

1. Direct-Service Intervention Name (See “Direct-Service Intervention Name List” attachment for a list of direct-service intervention names. Please enter the name exactly as it appears on the list. If your planned direct-service intervention is not included on the list, please write it in on the “Other” line below) _____________________________________________

Other: ________________________________________

2. Date Added |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Objectives (enter the name of the objectives you identified in Section 4.2 that are relevant to this direct-service intervention):

_______________________________________

4. Intervention Target(s) (select all that apply)

• SA

• HIV

• Viral hepatitis

• Other (Specify) _______________________________________

5. Intervention Description _____________________________________________________

6. Does this direct-service intervention target (select only one)

• Individuals

• Community

• Both

7. Is this direct-service intervention evidence-based? (select only one)

• Yes

• No

8. Evidence-based Justification (completed if “Yes” is selected for “Is this direct-service intervention evidence-based?”; select all that apply)

• Inclusion in a Federal List or Registry of evidence-based interventions

• Being reported (with positive effects) in a peer reviewed journal

• Documentation of effectiveness based on all three of the following criteria: 1) based on solid theory validated by research; 2) supported by a body of knowledge generated from similar interventions; 3) consensus among informed experts of effectiveness based on theory, research, practice and experience

9. Do you plan to adapt this direct-service intervention from the original? (completed if “Yes” is selected for “Is this direct-service intervention evidence-based?”; select only one)

• Yes

• No

10. Description of Adaptation_____________________________________________________

(completed when “Yes” is selected for “Do you plan to adapt this direct-service intervention from the original?”)

11. Status (select only one)

• Active

• Inactive

5. Direct Service Planning

Definition: A direct service is a service delivered to an individual or a group in face-to-face interaction. Typically, the service provider and participant are in the same location at the same time.

Instructions: An intervention may contain a single service or a bundle of services working together to achieve the intervention’s objective(s). Complete all items in this section separately for each Planned Direct-Service Intervention you entered in Section 4.4. For an intervention composed of multiple direct services, complete Items 4.5.2 – 4.5.7 below for each service separately.

1. Direct-Service Intervention Name (enter the Direct-Service Intervention Name you listed in Section 4.4.1): _______________________________________

2. Name of Direct Service (select only one; complete Section 4.5 separately for each additional direct service associated with the intervention)

• Risk and/or resiliency strength assessment

• Risk reduction counseling/education

• HIV testing

• Viral hepatitis (VH) testing

• STD testing (other than HIV and VH)

• Testing counseling

• Viral hepatitis (VH) vaccinations

• Psycho-social counseling

• Substance abuse counseling

• Mentoring (peer or other type)

• Case management services

• Primary health care services

• Health care services other than primary

• Support group

• Group counseling/therapy

• Skills building training/education

• General health education

• General STD education

• Viral hepatitis (VH) education

• HIV education

• Substance abuse education

• Cultural enhancement activities

• Drug-free alternative activities (e.g. supervised alcohol-free parties, picnics, etc.)

• Other (Specify) ___________________________

3. Planned Direct Service Begin Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

4. Planned Direct Service End Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

5. Frequency __________________________________________________

6. Dosage ____________________________________________________

7. Is this direct service part of the prescribed curriculum for this intervention? (completed if “Yes” is selected for “Is this intervention evidence-based?” in Section 4.4.7; select only one)

• Yes

• No

6. HIV Testing Planning

1. How does your organization plan to provide HIV testing services? (select all that apply)

• Rapid HIV testing will be provided by the grantee organization

• Rapid HIV testing will be available through referral to an outside organization

• Confirmatory HIV testing will be available through referral to an outside organization

2. Please describe how HIV testing will be conducted and where (e.g. off site, local health department, subcontract, hospital, etc.): ____________________________________

3. How many people do you expect will receive an HIV test using CSAP/MAI grant funds? _______

7. Viral Hepatitis (VH) Testing Planning

[NOTE: This section is for MSI CBO 2014, MSI CBO 2015, and HIV CBI grantees only]

1. How does your organization plan to provide VH testing services? (select all that apply)

• Rapid VH testing will be provided by the grantee organization

• Rapid VH testing will be available through referral to an outside organization

• Confirmatory VH testing will be available through referral to an outside organization

2. Please describe how VH testing will be conducted and where (e.g. off site, local health department, subcontract, hospital, etc.): ____________________________________

3. How many people do you expect will receive a VH test using CSAP/MAI grant funds? _______

8. Viral Hepatitis (VH) Vaccination Planning

[NOTE: This section is for HIV CBI grantees only and is optional]

1. How does your organization plan to provide VH vaccination services? (select all that apply)

• VH vaccinations will be provided by the grantee organization

• VH vaccinations will be available through referral to an outside organization

2. Please describe how VH vaccinations will be conducted and where (e.g. off site, local health department, subcontract, hospital, etc.): ____________________________________

3. How many people do you expect will receive a VH vaccination using CSAP/MAI grant funds? _______

9. Indirect Service Planning

Definitions:

Indirect Service: A prevention activity intended to change the institutions, policies, norms, and practices of entire community or to disseminate information to the entire community. Typically, the service is delivered to an entire population rather than a specific individual or a group and the service provider and service recipients are not necessarily in the same location at the same time.

Environmental Strategy: A prevention activity intended to change community standards, codes, and practices, related to undesirable health behaviors in the general population (e.g. changes in rules and regulations or systems changes at the organization or community level).

Information Dissemination: A prevention activity intended to provide knowledge about undesirable health behaviors and their adverse effects, or about available behavioral health services, to an entire community (e.g. media campaigns, informational brochures, posters, web sites, etc.)

Instructions: Complete all items in this section separately for each Indirect Service you are planning.

1. Date Added |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Objective(s) (list the objective(s) you identified in Section 4.2 that are relevant to this indirect service)

_______________________________________

_______________________________________

_______________________________________

3. Indirect Service Type (select only one)

• Environmental Strategy

• Information Dissemination

4. Indirect Service

If Environmental Strategy is selected as the Indirect Service Type, select one of the following indirect services:

• Efforts to improve neighborhood or campus safety

• Enhancing accesses to SA/HIV/VH prevention services

• Enforcement efforts (e.g. compliance checks, sobriety checkpoints, dormitory inspections)

• Collaboration with law enforcement

• Educating elected officials or other community leaders

• Training environmental influencers (e.g. police, beverage servers, healthcare providers, campus administrators)

• Efforts to increase sanctions for alcohol or drug use

• Condom distribution

• Enhancing access to HIV and/or viral hepatitis testing through health policy or organizational change

• Promoting changes to alcohol pricing and/or taxation

• Gathering of Native Americans (GONA)

• Promoting policy changes to limit alcohol advertising

• Promoting policy changes (e.g. in workplaces or campuses) to prevent sexual violence

• Other efforts to change community or organizational policies

• Other (Specify) ____________________________________

If Information Dissemination is selected as Indirect Service Type, select one of the following indirect services:

• Public speeches or lectures

• Town hall meetings

• Social marketing or social norms campaigns

• Prevention-focused websites

• Information dissemination through social media (e.g. Facebook, Twitter, YouTube)

• E-mail blasts

• Instagram

• Applications for mobile devices (e.g. Smart phones, tablets)

• Posters or billboards

• Public service announcements (PSA) on radio or television

• Newspaper or magazine advertisements

• Newspaper articles or letters to the editor

• Informational booklets, brochures, flyers or newsletters

• Workshops, seminars, or symposiums

• Social norms campaigns

• Health fairs

• Condom demonstrations

• Health & fitness promotions and demonstrations

• Information phone lines or hotlines

• Other (specify) __________________________________

5. What does this indirect service target? (select all that apply)

• SA

• HIV

• Viral hepatitis

• Other (Specify) ___________________________________

6. Environmental Strategy Purpose (completed if Environmental Strategy is selected for Indirect Service Type; select all that apply)

• Limit access to substances

• Change culture and context within which decisions about substance use or sexual behaviors are made

• Change physical design of the environment (e.g. improve lighting, add emergency phones)

• Reduce negative consequences associated with substance use or risky sexual behaviors

• Enhance access or reduce barriers to prevention and healthcare resources

• Increase access to condoms or other forms of protection

• Change social norms

• Reduce glamorization of substance abuse

• Increase pricing of alcohol

• Increase penalties or sanctions

• Capacity/coalition building

• Educate for policy change

• Increased access to viral hepatitis vaccine

• Other (Specify) ___________________________

7. Information Dissemination Purpose (completed if Information Dissemination is selected for Indirect Service Type; select all that apply)

• To raise awareness of substance abuse, HIV, or viral hepatitis related problems in the community

• To gain support from the community for your prevention efforts

• To provide information on community norms related to substance use or sexual behaviors

• To provide information on the harms of substance use or risky sexual behaviors

• To provide information on how to prevent substance abuse or HIV/VH transmission among family and friends

• To change individual behaviors with regard to substance use or risky sexual behaviors

• To provide intervention program information (e.g., contact information, meeting times)

• To provide surveillance and monitoring information (e.g., information about whom to contact if you witness underage alcohol sales or consumption)

• To provide information about prevention and healthcare resources in the community

• To educate for policy change

• Other (Specify) ____________________________________________

8. Indirect Service Description ____________________________________________

9. Planned Indirect Service Begin Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

10. Planned Indirect Service End Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

11. How many people do you plan to reach through this indirect service? _________

12. Is this indirect service evidence-based? (select only one)

• Yes

• No

13. Evidence-based Justification (completed if “Yes” is selected for “Is this indirect service evidence-based?”; select all that apply)

• Inclusion in a Federal List or Registry of evidence-based interventions

• Being reported (with positive effects) in a peer reviewed journal

• Documentation of effectiveness based on all three of the following criteria: 1) based on solid theory validated by research; 2) supported by a body of knowledge generated from similar interventions; 3) consensus among informed experts of effectiveness based on theory, research, practice and experience

10. Accomplishments and Barriers

5. Type (fill out this section separately for each additional accomplishment or barrier; select only one and please include the date associated with the accomplishments and barriers)

Date:

• Accomplishment

• Barrier

1. Accomplishment/Barrier Name _________________________________________

2. Description ________________________________________________

11. Conclusions and Recommendations

[Optional]

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

5. Implementation

[Frequency: Completed quarterly during the Implementation phase]

Implementation is the point at which the activities developed and defined in the Assessment, Capacity, and Planning steps are conducted.

1. Numbers Served

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many people did you serve through direct-service interventions? _________

3. So far this federal fiscal year, how many people did you serve through direct-service interventions, by the following target population? (Enter the number served by target population in the second column below; note, the number served for any given target population should not exceed the total served you entered above in 5.1.2):

Target Population	Number Served
Adolescents (Age 12-17)
Young Adults (Age 18-24) in college
Young Adults (Age 18-24) not in college
Older Adults (Age 50 and Over)
American Indian/Alaska Natives
Asian American/Pacific Islanders
Black/African American Women
Black/African American Men
Latina or Hispanic Women
Latino or Hispanic Men
Men Having Sex with Men (MSM)
LGBTQ
Military/Veterans
Reentry Populations
Homeless
Sex Workers
Low Income
Other

2. Numbers Reached

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many people did you reach through indirect services? _________

3. So far this federal fiscal year, how many people did you reach through indirect-service interventions, by the following demographic categories? (Enter the number reached by demographic category in the second column below. If you do not know the exact number, please make your best estimate. Note, the number reached for any given demographic category should not exceed the total reached you entered above in 5.2.2):

Demographic Category		Number Reached
Gender	Female
	Male
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American/Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	Multiracial
	Missing
Age	Ages 12-17
	Ages 18 or Older
	Unknown

4. Is the number of people reached from indirect-service interventions actual or an estimate? (select only one)

• Actual

• Estimate

3. Grant Expenditures

1. Date Updated |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many grant dollars were spent on direct services? $_______

3. So far this federal fiscal year, how many grant dollars were spent on indirect services? $______

4. Total grant dollars spent during this federal fiscal year: $ ______

4. Direct-Service Intervention Implementation

Instructions: Complete this section separately for each implementation of each direct-service intervention you listed in Section 4.4. Each time a direct-service intervention is implemented on a different group of individuals, it counts as a separate implementation of that intervention. E.g., if a health education curriculum is delivered to three different groups, each of those count as a separate implementation of the intervention.

1. Date Implementation Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Date Implementation Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Direct-Service Intervention Name (Enter the Intervention Name you listed in Section 4.4.1) _______________________________________

4. Were all direct services/topics/sessions from the planned intervention covered?

• Yes

• No

5. How did the direct services/ topics/sessions differ from what was planned? _____________

(completed if “No” is selected for the question: Were all direct services/topics/sessions from the planned intervention covered?)

6. What are the reasons the intervention differed from planned? _______________________

(completed if “No” is selected for the question: Were all direct services/topics/sessions from the planned intervention covered?)

7. Retention Activities __________________________________________________________

8. Incentives to participants (select all that apply)

• Merchant Gift Cards

• Transportation

• Evaluation Incentives

• Other (Specify) __________________________________

5. Direct Service Implementation

Instructions: Complete this section separately each time you implement each of the Direct Services you listed in Section 4.5.

1. Date Service Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Date Service Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Direct Service Name (enter the Direct Service Name you listed in Section 4.5.2): _______________________________________

4. Location (this question is for MSI CBO grantees only; select all that apply)

• Campus

• Off-Campus

5. Location Description ________________________________________________

6. Location Zip Codes __________________________________________________

7. Frequency ___________________________

8. Dosage ______________________________

6. HIV Testing Implementation

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many people received an HIV test using CSAP/MAI funds? _______

2. So far this federal fiscal year, how many people received an HIV test for the first time using CSAP/MAI funds? _______

2. Please break down each of the above totals by demographic category in the columns below. The number tested for any given demographic category should not exceed the totals as reported above in 5.6.2 and 5.6.3.

Demographic Category		Received an HIV test using CSAP/MAI funds	Received an HIV test for the first time using CSAP/MAI funds
Gender	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American/Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	Multiracial
	Missing
Age	Ages 12-17
	Ages 18 or Older
	18-24
	25-34
	35-44
	45-54
	55-64
	65+
	Unknown

2. Of the total entered in 5.6.2 [i.e., total number of people who received an HIV test using CSAP/MAI funds],

   1. How many were homeless or unstably housed? _______

   2. How many were tested directly by the grantee organization or partner organization? _______

   3. How many tested positive for HIV? _____

   4. How many were informed of their HIV status? ______

   5. Of those who tested positive for HIV, how many were referred to treatment? ______

2. So far this federal fiscal year, how much was spent on HIV testing? ____

2. So far this federal fiscal year, how many HIV test kits did your agency purchase using CSAP/MAI grant funds? _____

7. Viral Hepatitis (VH) Testing Implementation

[NOTE: This section is for MSI CBO 2014, MSI CBO 2015, and HIV CBI grantees only]

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many people received a VH test using CSAP/MAI funds? _______

2. So far this federal fiscal year, how many people received a VH test for the first time using CSAP/MAI funds? _______

2. Please break down the total receiving a VH test by demographic category in the column below. The total for any given demographic category should not exceed the total reported in item 5.7.2.

Demographic Category		Received a VH test using CSAP/MAI grant funds
Gender	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Missing
Race	African American/Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	Multiracial
	Missing
Age	Ages 12-17
	Ages 18 or Older
	18-24
	25-34
	35-44
	45-54
	55-64
	65+
	Unknown

2. Of the total entered in 5.7.2 [total number of people who received a VH test using CSAP/MAI funds],

   1. How many were homeless or unstably housed? _______

   2. How many were tested directly by the grantee organization or partner organization? _____

   3. How many tested positive for VH? _____

   4. How many were informed of their VH status? _____

   5. Of those who tested positive for VH, how many were referred to treatment? ______

2. So far this federal fiscal year, how much was spent on VH testing? _____

2. So far this federal fiscal year, how many VH test kits did your agency purchase using CSAP/MAI grant funds? _____

8. Viral Hepatitis (VH) Vaccination Implementation

[NOTE: This section is for HIV CBI grantees only and is optional]

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many people received a VH vaccination (e.g. Twinrix) using CSAP/MAI funds? _______

3. Please break down the total receiving a VH vaccination by demographic category in the columns below. The number that received VH vaccination by any given demographic category should not exceed the total as reported above in 5.8.2.

Demographic Category		Received a VH vaccination using CSAP/MAI grant funds
Gender	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American/Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	Multiracial
	Missing
Age	Ages 12-17
	Ages 18 or Older
	18-24
	25-34
	35-44
	45-54
	55-64
	65+
	Unknown

4. Of the total entered in 5.8.2 [i.e., total number of people who received a VH vaccination using CSAP/MAI funds],

   1. How many were homeless or unstably housed? _______

   2. How many were tested directly by the grantee organization or partner organization?

_______

5. So far this fiscal year, how much was spent on VH vaccinations? ____

6. So far this fiscal year, how many VH vaccines did your agency purchase using CSAP/MAI grant funds? _____

9. Referrals for Services Not Funded By MAI Funds

Instructions: This section collects information about MAI program participants referred for further services that were not delivered by the grantee and/or partner organization and were not funded through MAI funds. Complete this section for referrals to services not funded by MAI funds.

1. Referred by (this item is for MSI CBO grantees only; select only one)

• MSI

• CBO

2. So far this federal fiscal year, how many referrals did you make? _______

3. Of the total reported above, please report the number of referrals you made to each service...

Service	Number of Referrals
HIV Testing
HIV Testing Counseling
HIV Treatment
VH Testing
VH Counseling
VH Vaccination
VH Treatment
Substance Abuse Treatment
Mental Health Services (excluding HIV testing counseling and VH testing counseling)
Health Care Services (excluding SA, HIV, and VH treatment)
Supportive Housing
Other Social Services (Specify) ______________
Other Service Type (Specify) _______________

5. So far this fiscal year, what is the number of participants who received the service for which they were referred? ________

10. Indirect Service Implementation

Instructions: Complete this section separately for each time you implement each Indirect Service you entered in Section 4.9.

1. Implemented by (this item is for MSI CBO grantees only; select only one)

• MSI

• CBO

2. Date Service Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Date Service Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

4. Indirect Service (Enter the Indirect Service you listed in Section 4.9.4) _______________________________________

5. Did implementation of this indirect service go according to plan?

• Yes

• No

6. How did implementation differ from the planned indirect service? _______________________

(completed if “No” is selected for the question: Did Implementation of this indirect service go according to plan?)

7. What are the reasons this indirect service differed from planned? _______________________

(completed if “No” is selected for the question: Did Implementation of this indirect service go according to plan?)

11. Participant Outreach/Recruitment Activities

Instructions: Complete this section separately for each outreach/recruitment activity conducted during the quarter.

1. Date Activity Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Date Activity Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Activity Name ________________________________________________

4. Activity Description ________________________________________________________

5. During this quarter, how many people did you reach through these recruitment activities? ________

12. Accomplishments and Barriers

Enter information on any Accomplishments and/or Barriers that you had while performing activities related to Implementation.

6. Type (fill out this section separately for each additional accomplishment or barrier; select only one and please include the date associated with the accomplishments and barriers)

Date:

• Accomplishment

• Barrier

1. Accomplishment/Barrier Name ___________________________

2. Description ________________________________________________

13. Conclusions and Recommendations

[Optional]

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

6. Evaluation

[Frequency: Completed at least once during the Evaluation phase, updated as needed]

The Evaluation Step is comprised of conducting, analyzing, reporting on and using the results of Outcome Evaluation. The Outcome Evaluation involves collecting and analyzing information about whether the intended Goals and Objectives were achieved. Evaluation results identify areas where modifications to prevention strategies may be needed, and can be used to help plan for sustaining the prevention effort as well as future endeavors.

1. Evaluation Plan

1. Upload/Attach Evaluation Plan

2. Please describe any finding that you would like to highlight: ________________________________________________

3. Upload/Attach Supporting Documents

2. Evaluation Report

1. Upload/Attach Evaluation Report

2. Is this Evaluation Report a draft or final version? (select only one)

• Preliminary

• Final

3. Upload/Attach Supporting Documents

[Enter outcome data for your indirect services in the “MAI HIV Indirect Services Outcomes Reporting Tool”]

3. Accomplishments and Barriers

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one and include date associated with the accomplishment and barriers)

Date:

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name _________________________________________

3. Description ________________________________________________

4. Conclusions and Recommendations

[Optional]

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

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