Form 1 PIMS

Rural Opioid Overdose Reversal Grant Program

Performance Improvement Measurement System (PIMS)

Demographics

Type of organization Denotes the type of organization for the lead grantee administering the grant (health department; hospital; fire department; police department; school; county, state, or city government; etc).
Number of counties served Denotes the total number of counties served through the program. Please include entire, as well as partial counties served through the grant program. If your program is serving only a fraction of a county, please count that as one (1) county.	This field only accepts whole numbers, including 0. Represents the number of counties served.
Partnership Organizations Denotes the name of all of the organizations in the partnership and their type.	Name of Organization This field accepts alphanumeric characters and expands.		Type of Organization Selection list  Hospital/Clinic Rural Health Clinic CAH Health Department Fire Department EMS Service Police Department Substance Abuse Facility Mental Health Facility Community Organization Other _______________
Type of device purchased Denotes the type of administration devices purchased. Selection list  Evzio Adapt intranasal  Intramuscular (syringe)	Number of devices purchased Denotes the number of devices purchased by type This field only accepts whole numbers, including 0	Cost of devices purchased Denotes the cost of devices purchased by type This field only accepts whole numbers, including 0
Were vials of medication purchased separately from those included with the device?	Yes (If field is clicked yes, go to next two questions – number of vials and cost of medication will be hidden unless yes is clicked) No (if field is clicked no, go to distribution points question)
Number of vials of medication purchased (if purchased separately from the device)	This field only accepts whole numbers, including 0.
Total Cost of medication (if purchased separately from the device)	This field only accepts whole numbers, including 0.
Distribution points for the devices/medication Denotes who received the devices/medication. (This field expands since distribution can be more than one entity) Selection list Fire trucks Ambulances Police cruisers Hospital or other health facility Community organization _(type of organization) Individuals Other __specify	Number distributed Denotes the number of devices/medication distributed by type of entity. This field only accepts whole numbers. If “0” is entered, prompt error message. Field must be completed before moving to next question.

USAGE and REFERRAL

Number of uses Denotes the number of times naloxone/narcan was administered. This field only accepts whole numbers, including 0 and DK.	Disposition after usage Denotes the disposition of the individual after administration. This field accepts whole numbers, including 0 and DK. Number of individuals in which opioid overdose was reversed ______
Were any individuals transported to a health care facility? Yes (if yes, go to number of individuals transported question) No (if not, go to next question below- referred for further treatment) Unknown Other notes_________	If yes, number of individuals transported to a health care facility. This field only accepts whole numbers, including 0 and DK.
Were any individuals referred for further treatment? (Check all that apply) Substance abuse treatment facility (if checked go to number of referrals) Mental health (counseling) services (if checked go to number of referrals)	Number of referrals by type of treatment. This field only accepts whole numbers. Substance abuse treatment facility _____ Mental health (counseling) services  Within hospital/medical clinic _____  Doctor’s office ______  Private office of psychologist/psychiatrist/therapist ____  School/university setting _____  Other (indicate name)____________ # referrals _____
Was there report of any violent or erratic behavior after administration of naloxone?	Yes I f yes, number of episodes _________ No Unknown

TRAININGS

Type of training Denotes the number of trainings related to use of naloxone/narcan (how to use the administration devices, how much medication to dispense, signs of overdose, etc.)	Number of trainings	Number of responders trained (police, fire, EMS, health facility staff)	Number of laypersons trained	Total Cost of training by type
In person	This field only accepts whole numbers, including 0.	This field only accepts whole numbers, including 0	This field only accepts whole numbers, including 0	This field only accepts whole numbers, including 0
Video/webinar	This field only accepts whole numbers, including 0	This field only accepts whole numbers, including 0	This field only accepts whole numbers, including 0	This field only accepts whole numbers, including 0
Was instruction on Basic Life Support/Advanced Life Support provided? Yes No	If yes, number of trainings This field only accepts whole numbers, including 0		If yes, number trained This field only accepts whole numbers, including 0
Was instruction on use of an Automatic External Defibrillator provided? Yes No	If yes, number of trainings This field only accepts whole numbers, including 0		If yes, number trained This field only accepts whole numbers, including 0