Form 39 Substance Abuse Progress Report

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
SUBSTANCE ABUSE PROGRESS REPORT

FOR HRSA USE ONLY
Grant
Number

Current
reporting
period

1.       Substance Abuse Activities

Progress
Report
Tracking
Number
Cumulative
Total

1a.

How many physicians, on-site or with whom the health center has contracts,
have obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat
opioid use disorder with medications that have been specifically approved by the
FDA for that indication?

To be
calculated by
HRSA

1b.

How many patients received medication-assisted treatment for opioid use
disorder from a physician with a DATA waiver working on behalf of the health
center?

To be
calculated by
HRSA

2. Issues/Barriers (for the current reporting period only)
For the current reporting period, describe up to three major issues/barriers that you experienced while conducting substance
abuse expansion activities.

Required; up to 2500 characters (1 page)
3. Key Strategies and Lessons Learned (for the current reporting period only)
For the current reporting period, describe up to three strategies that contributed most to the success of your substance abuse
expansion activities.

Required; up to 2500 characters (1 page)

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 0915-0285.
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for
reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857