Form CLI

SPF-PFS Cross-Site Evaluation, Community Level Instrument - Revised

Form Approved

OMB No. xxxxx

Expiration Date xxxx

Strategic Prevention Framework
Partnerships for Success
(SPF-PFS)

Community-Level Instrument—Revised (CLI-R)
October 2014

Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Prevention

Burden Statement: Public reporting burden of this collection of information is estimated to average between 30 minutes and 2.5 hours per response. Send all comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, Choke Cherry Road, Rockville, MD 20857. An agency may not sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The control number for this project is xxxx-xxxx.

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able of Contents

Information and Directions 1

Purpose 1

Requirements 1

Organization of the Survey 1

Inclusion of Key Informants 2

Helpful Materials 2

Entering and Saving Data 2

Survey Assistance 2

Definition of Terms 3

Section 1: Administrative Survey 5

Organization Type 5

Funding 6

Cultural Competence and Health Disparities 7

Section 2: Strategic Prevention Framework 8

Section 2A. Needs and Resources Assessments 8

Data Sources 9

Targeted PFS Needs 15

Section 2B. Capacity Building 18

Organizational Resources 19

Training and Technical Assistance 20

Relationship Building 20

Data Infrastructure 22

Sustainability 23

Section 2C. Strategic Plan Development 24

Section 2D. Prevention Intervention Implementation 25

Implemented Prevention Interventions 26

Prevention Intervention Information 29

Community-Based Processes Sub-Form 34

Prevention Education Sub-Form 40

Alternative Drug-Free Activities Sub-Form 47

Problem Identification and Referral Sub-Form 55

Environmental Strategies Sub-Form 62

Information Dissemination Sub-Form 73

Prevention Intervention Costs 86

Adaptations 95

Section 2E. Monitoring and Evaluation 98

Section 3: Contextual Factors 100

Section 4: Closing Questions 102

NOTE Timing of Instrument Items: B = Baseline; A = Annual; E = Every time (twice per year); F = Final

Strategic Prevention Framework Partnerships for Success (SPF-PFS)
Cross-Site Evaluation, Community-Level Instrument

Information and Directions

Purpose

The Community-Level Instrument—Revised (CLI–R) collects data about:

• The subrecipient community’s progress through the Strategic Prevention Framework (SPF); and

• The specific prevention interventions being implemented by the community.

Data collected from the survey will be used to monitor subrecipient and State, tribal entity, or jurisdiction performance; provide information for Government Performance and Results Act (GPRA) reporting; and evaluate the effectiveness of the Strategic Prevention Framework Partnerships for Success (SPF-PFS) program across States, tribal entities, and jurisdictions. The overall goal of the cross-site evaluation is to document and assess the effectiveness of the PFS approach to SAMHSA’s mission of reducing underage drinking and prescription drug misuse and abuse.

Requirements

Completion of this survey is a requirement of accepting funding from CSAP through your State, tribal entity, or jurisdiction under the PFS grant initiative.

Organization of the Survey

Make sure to read all of the directions and examples, which are provided in italics. Information on progress through SPF steps and costs of interventions will be collected once each Federal fiscal year (annually), whereas information on implementation of your community’s interventions, including the number reached or served by the interventions, will be collected twice each Federal fiscal year (semiannually). To minimize respondent burden and decrease completion time, this Web-based survey allows information entered in previous reporting periods to be prefilled where possible and uses skip patterns to take you automatically to the appropriate question on the basis of your responses. In addition, the Web-based form will display only those questions you are required to complete at that data collection time point (e.g., SPF progress items only once a year).

Each subrecipient community will complete separate forms related to implementation information for each set of prevention intervention activities implemented. For example, if the community implements both a participant-based education prevention intervention strategy and an environmental prevention intervention strategy, they will complete implementation information for both of those interventions. Similarly, if the community implements two different participant-based education prevention intervention strategies, they will complete implementation information for both of those interventions.

Information provided in this instrument focuses on communities, so no individuals will be identified in the reporting of results.

Throughout this instrument, the term “you” refers to the subrecipient community that has received SPF-PFS funding from the State/tribal entity/jurisdiction. The subrecipient community could be an organization, coalition, or other entity.

Inclusion of Key Informants

You are strongly encouraged to obtain input from others involved with the SPF-PFS-funded project. Each section of the instrument includes a list of individuals whom you may want to consider consulting in this data collection effort. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, as appropriate and relevant for your SPF-PFS grant.

People you may want to include in responding to the CLI-R (if these positions are applicable to your grant)—

• Project Director

• Project Coordinator

• Person with responsibility or knowledge of financial issues

• Staff responsible for renting space, purchasing equipment, and doing similar activities

• State Epidemiology and Outcomes Workgroup (SEOW) Liaison

• Data Coordinator

• Local Evaluator

• Intervention delivery staff

• Coalition representatives

• Key stakeholders or partners

Helpful Materials

Before completing the survey, you may find it helpful to gather the following materials to help answer questions:

• Budgets;

• Results of needs and resources assessments;

• Strategic plans;

• Meeting minutes;

• Memoranda of understanding;

• Prevention intervention implementation materials (curricula, programs, etc.);

• Evaluation findings and reports; and

• Organizational policies.

Entering and Saving Data

As you enter your data, you will be able to save your work and come back to it at another time. You may also write your responses to the open-ended questions requiring narrative information in advance using a word processor and copy and paste them into the Web-based survey.

Survey Assistance

If you need assistance in using the Web-based data entry system, contact the Help Desk by leaving a message at (866) 558–0724 or by email at [email protected]. You can request assistance at any time and someone will respond to you within 24 hours or the next business day.

Definition of Terms

There are several terms used throughout this instrument for which CSAP provides the definitions on the following pages. Links to the definitions list can be found on each page of the Web-based survey.

• Capacity refers to the quality and/or level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF-PFS, capacity refers to the demonstrated ability of subrecipients to implement each SPF step effectively (e.g., implementation of evidence-based interventions) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model.

• Capacity building refers to activities conducted to improve the ability of an organization or community to deliver substance abuse prevention services, such as improving organizational resources; improving awareness about substance abuse problems; building new relationships or strengthening existing relationships among coalitions, groups, and organizations involved in substance abuse prevention; and working to ensure that prevention intervention activities and outcomes continue after funding ends.

• Community refers to the politically or geographically defined area or culturally or epidemiologically defined target population that the subrecipient chooses for prevention intervention.

• Community needs and resources assessments examine needs and resources external to the organization and include community readiness, rates of substance use, prevention resources (e.g., call centers, trained implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.

• Community readiness is the community's level of awareness of, interest in, and ability and willingness to support substance abuse prevention initiatives. More broadly, it connotes readiness for changes in community knowledge, attitudes, motives, policies, and actions.

• Consequences are defined as the social, economic, and health problems associated with the use of alcohol and illicit drugs—for example, illnesses related to alcohol (cirrhosis, fetal effects), drug overdose deaths, crime, and car crashes or suicides related to alcohol or drugs.

• Consumption patterns are the ways in which people drink, smoke, and use drugs, including how they misuse prescription drugs. Consumption includes overall consumption, acute or heavy consumption, consumption in risky situations (e.g., drinking and driving) and consumption by high-risk groups (e.g., youth, college students, pregnant women).

• Cultural competence is the knowledge, skills, and attitudes that enable administrators and practitioners to provide for diverse or culturally distinct populations. It includes an understanding of that group’s or members’ language, beliefs, norms, and values, as well as socioeconomic and political factors that may have a significant impact on their well-being, and the ability to incorporate those variables into interventions.

• Dosage describes the level of exposure to an intervention, as defined by the number of sessions, number of media spots, or other measures.

• Environmental approaches are efforts to establish or change community standards, codes, and attitudes and thus reduce the incidence and prevalence of substance abuse. Approaches can center on legal and regulatory issues or can relate to service and action-oriented initiatives. Examples include technical assistance (TA) to communities to maximize enforcement of laws governing availability and distribution of legal drugs, modification of policies and practices, and training of environmental influencers such as beverage servers or health practitioners.

• Federal fiscal year goes from October 1 through September 30 of the following year.

• Intervening variables are risk or protective factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of substance use and related risk behaviors and their consequences. These variables are the focus of prevention interventions, changes in which are then expected to affect consumption and consequences.

• In-kind resources include labor that supports the SPF-PFS grant at subsidized or no cost to the grant or other resources donated to the SPF-PFS grant, such as equipment, supplies, or office space.

• Interventions are funded activities carried out under the auspices of the SPF-PFS grant. They target a variety of subpopulations with the objective of improving substance use outcomes.

• Key stakeholders are all the members of the community who have a vested interest (a stake) in the activities or outcomes of a substance abuse intervention.

• Leveraging resources is the process of combining PFS-funded resources with other resources to augment prevention intervention delivery (i.e., to do more together than with PFS resources alone). For example, subrecipients combine PFS funding with funding from another source (e.g., a Drug-Free Communities partner) to augment the implementation of their PFS intervention. In many instances, leveraging functions through collaborative relationships.

• Participants are the recipients of the PFS prevention interventions.

• Primary grantee refers to the administrative entity (such as the State, tribal entity, or jurisdiction) receiving SPF-PFS funds for delivery of substance abuse prevention interventions.

• Social marketing uses the principles of commercial marketing to develop, implement, and evaluate interventions designed to influence the behavior of a target audience.

• Strategic plans at a minimum will specify the priorities that will be targeted, articulate a vision for activities to address needs, describe infrastructure needed to select and implement interventions, identify resources and training requirements, include plans for sustaining the infrastructure and services, and identify milestones and outcomes against which to gauge performance. Strategic plan development is Step 3 of the SPF.

• Subrecipients are the entities (usually community-based organizations, schools, or coalitions) that receive funds from the grantee and carry out SPF-PFS activities or prevention interventions.

• Sustainability is the process through which a prevention system becomes a norm and is integrated into ongoing operations. Sustainability is vital to ensuring that prevention values and processes are firmly established, that partnerships are strengthened, and that financial and other resources are secured over the long term.

Section 1: Administrative Survey

This section asks questions that describe your subrecipient organization. Your subrecipient organization should be identified in terms of the entity that is carrying out the activities of the SPF-PFS. This section includes questions about funding sources and policies that have been developed that address cultural competence and health disparities.

Organization Type

Subrecipient Name (System prefill)^{E (locked)}

________________________________________________________________________________

1. What type of organization would you say you are? You should identify your organization in terms of the entity that will be carrying out the activities of the SPF-PFS. (Select the one response that best describes your organization.) ^{B, F}

• We are a Community Coalition. (If selected, you will automatically proceed to Question 3.)

• Youth-focused local grassroots or community-based service or advocacy organization (e.g., local chapter of Students Against Destructive Decisions [SADD], local youth councils, Boy Scouts/Girl Scouts, Big Brothers/Big Sisters)

• Non-youth-focused, local grassroots or community-based service or advocacy organization (e.g., substance abuse prevention organizations, HIV prevention organizations, YMCAs)

• Faith-based organization

• Other nonprofit organization, not listed above

• School or school district

• Law enforcement organization

• College or university

• Government agency

• Tribal entity or organization

• Local health care facility or treatment or prevention provider or facility (e.g., local hospital, community mental health center, local substance abuse prevention agency)

• Other (Describe.) ______________________________________________________

2. Are you partnering with a Community Coalition? By partnering, we mean that you have a formal relationship that is documented with a memorandum of understanding or similar agreement and/or that you provide SPF-PFS funding. (Select one response.) ^{B, F}

• Yes

• No (If selected, you will automatically proceed to Question 4.)

3. Indicate the role of the Community Coalition in changing community capacity, knowledge, norms, and behaviors related to substance abuse prevention and intervention implementation. (Select all that apply.)^{B, F}

• Collect and organize data

• Conduct needs assessments

• Train community members in substance abuse prevention

• Leverage funds from sources other than PFS

• Leverage resources other than funding (e.g., personnel, space, supplies)

• Plan or implement prevention interventions

• Ensure that PFS-funded prevention interventions address issues related to cultural competence

• Plan or implement process or outcome evaluations of prevention interventions

• Set substance abuse policy at the organizational, local, State, or tribal level

• Educate others about needed changes in substance abuse policy at the organizational, local, or State/tribal/jurisdiction level

• Other (Describe.) _______________________________________________________

Funding

4. Has your subrecipient organization (i.e., entity that will be carrying out the activities of the SPF-PFS) received SPF SIG funding in the past?^B

• Yes (If selected, you will automatically proceed to Question 6)

• No

• Don’t know

5. Has your subrecipient organization (i.e., entity that will be carrying out the activities of the SPF-PFS) been part of a coalition or group or organizations that received SPF SIG funding in the past?^B

• Yes

• No

• Don’t know

Cultural Competence and Health Disparities

These questions collect information on how your subrecipient organization (i.e., entity that will be carrying out the activities of the SPF-PFS) addresses cultural competence and health disparities.

6. Does your organization have formal, written policies in place to address cultural competence? For purposes of this question, we are interested only in formal, written policies. (Select one response.)^{B, F}

• Yes, we do have formal, written policies to address cultural competence

• We do not have formal polices to address cultural competence but are required to follow the policies of the fiscal agency through which the SPF-PFS funds are funneled

• We are aware that cultural competence is an issue but we have not developed formal, written policies yet, or these policies are currently being developed

• Not applicable—we are a coalition or other organization type that does not have formal policies

7. Health disparities subpopulations refer to specific demographic, language, age, socioeconomic status, sexual identity, or literacy groups that experience limited availability of or access to substance use prevention services OR who experience worse substance use prevention outcomes. Which of the following health disparities-related activities did your subrecipient organization conduct during the past 6 months? (Select all that apply.)^E

• Defined specific health disparities subpopulations (by demographics, language, age, socioeconomic status, sexual identity, or literacy)

• Identified specific substance use-related health disparities faced by your selected subpopulations

• Obtained substance use-related data specific to the high-needs subpopulations

• Considered health disparities in your PFS planning process (e.g., in subrecipient or intervention selection)

• Involved subpopulations experiencing health disparities in your PFS activities (e.g., assessment, capacity building, planning, implementation, or evaluation)

• Received training to increase your capacity related to substance use health disparities

• Developed partnerships with agencies, organizations, or key stakeholders to address the health disparities

• Implemented interventions specifically for health disparities subpopulations

• Adapted interventions to make them apply to specific health disparities subpopulations

• Increased the availability of substance use prevention services to health disparities subpopulations (i.e., increased how many services exist for these populations)

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

• Evaluated outcomes by subpopulations that face substance use health disparities

• Evaluated changes in the number of individuals served or reached by subpopulations that face substance use health disparities

• Developed a plan to sustain progress made in addressing substance use-related health disparities beyond the Partnerships for Success Initiative

Section 2: Strategic Prevention Framework

Each step of the Strategic Prevention Framework is addressed in this section.

The five steps include:

• Needs and resources assessments

• Capacity building

• Strategic plan development

• Prevention intervention implementation

• Monitoring and evaluation

You will have the opportunity to describe your activities for each of the steps you worked on during this reporting period.

Section 2A. Needs and Resources Assessments

This section collects information on organizational and community needs and resources assessments you conducted during this reporting period. You are asked whether or not the needs and resources of your organization and the community have been assessed. It also provides you with an opportunity to describe the data you have available and the data you used to conduct your needs and resources assessment. Finally, the section asks about the consumption patterns, consequences, intervening variables, and populations you identified to target for your PFS activities.

8. Has your organization completed an assessment of community needs and resources during the past Federal fiscal year? A community needs and resources assessment examines needs external to the organization and includes community readiness, rates of substance use, prevention resources (e.g., trained intervention implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.^A

• Yes

• No (If selected, you will automatically proceed to Question 10 and skip Question 14.)

9. Indicate the types of community needs and resources that were assessed during the past Federal fiscal year. (Select all that apply.)^A

• Needs of hard-to-reach populations (e.g., homeless, undocumented workers)

• Needs of populations facing health disparities

• Factors that might cause, lead to, or promote substance use

• Substance use rates of potential target populations

• Substance use consequences in potential target populations (e.g., alcohol-related mortality)

• Community readiness for implementing substance use prevention interventions

• Presence of other substance use prevention intervention efforts

• Cultural competence of existing substance use-related interventions and policies

• Prevention resources (e.g., trained implementers)

• Funding sources for substance use prevention interventions

• Partnerships with relevant organizations in the community

• Experience within the community of working with potential target populations (e.g., previous encounters with the target population, such as serving members with prevention services or conducting outreach)

• Workforce training issues within the community (e.g., not enough slots in a community-college training program)

• Other (Describe.) _____________________________________________________

Data Sources

This set of questions asks about the availability of community-level alcohol- and prescription drug-related data for data-driven planning (e.g., needs assessments, identifying priority issues and intervening variables to target, performance monitoring). We want you to focus on local data collection sources that exist in your subrecipient community.

10. Does your organization have access to local data collection sources related to alcohol or prescription drug consumption, consequences, or risk and protective factors in your subrecipient community? Examples include local community or school surveys and administrative data sources on arrests, automobile crashes, and emergency room visits. ^{B, F}

• Yes, but all of your local data is provided to you by your State, tribal entity, or jurisdiction (If selected, you will automatically proceed to Question 14.)

• Yes, you have access to some local data that is obtained by you from a source other than your State, tribal entity, or jurisdiction

• No (If selected, you will automatically proceed to Question 14.)

Under each of the categories Consumption, Consequence, and Risk and Protective Factors, list the data sources, including local surveys and administrative data collection systems, that currently exist in your subrecipient community.

11. Local data sources for alcohol or prescription drug consumption (do not include data provided directly by your State, tribal entity, or jurisdiction)^{B, F (autofill once completed initially)}

11a. Data source	11b. Substance(s) (Select all that apply)	11c. Frequency of data collection (Select one response)	11d. Most recent data collection time point (Year)	11e. Geographic level(s) of data availability (Select all that apply)	11f. Subgroup level(s) of data availability (Select all that apply)	11g. Respondents or population(s) (Select all that apply)
1) (Fill in data source name here) ________________________________________________________________________________________	Alcohol—weekly use Alcohol—past 30-day (or month) use Alcohol—past year use Alcohol—lifetime use Alcohol—heavy drinking Alcohol—binge drinking Prescription drugs—weekly misuse Prescription drugs—past 30-day (or month) misuse Prescription drugs—past year misuse Prescription drugs—lifetime misuse Other (describe) _____________________________	Semi-annual Annual Every 2 years Other (describe) ________________________________________________________________________________________		Region County School Neighborhood Other (describe) ________________________________________________________________________________________________	Race Ethnicity Gender Age Other (describe) ___________ _____________________________________________________________________________	Middle school students High school students College students General population Other (describe) __________________________________________________________________________________________________________________________________________________________________
2) (Fill in data source name here) ___________________________________________________________________________________________________	Alcohol—weekly use Alcohol—past 30-day (or month) use Alcohol—past year use Alcohol—lifetime use Alcohol—heavy drinking Alcohol—binge drinking Prescription drugs—weekly misuse Prescription drugs—past 30-day (or month) misuse Prescription drugs—past year misuse Prescription drugs—lifetime misuse Other (describe) _____________________________	Semi-annual Annual Every 2 years Other (describe) ________________________________________________________________________________________		Region County School Neighborhood Other (describe) ____________________________________________________________________________________	Race Ethnicity Gender Age Other (describe) ____________________________________________________________________________________	Middle school students High school students College students General population Other (describe) ________________________________________________________________________________________________________________________________________________

Example Consumption Data Source Table

11a. Data source	11b. Substance(s) (Select all that apply)	11c. Frequency of data collection (Select one response)	11d. Most recent data collection time point (Year)	11e. Geographic level(s) of data availability (Select all that apply)	11f. Subgroup level(s) of data availability (Select all that apply)	11g. Respondents or population(s) (Select all that apply)
1) County-wide school survey	Alcohol—weekly use Prescription drugs—weekly misuse	Every 2 years	2012	County School	Race Ethnicity Other (describe) Grade level	High school students
2) Communities that Care Survey	Alcohol—past 30-day (or month) use	Annual	2013	Other (describe) 8 neighborhoods within the county	Race Ethnicity Gender Age	Population (describe) Convenience sample—Youth surveyed in 3 shopping malls

12. Local data sources for alcohol or prescription drug consequences (do not include data provided directly by your State, tribal entity, or jurisdiction)^{B,F (autofill once completed initially)}

12a. Data source	12b. Consequence category (or categories) (Select all that apply)	12c. Frequency of data collection (Select one response)	12d. Most recent data collection time point (Year)	12e. Geographic level(s) of data availability (Select all that apply)	12f. Subgroup level(s) of data availability (Select all that apply)	12g. Respondents or population(s) (Select all that apply)
1) (Fill in data source name here) ______	Dependence or abuse Educational disruptiona Alcohol- and prescription drug-related arrests Alcohol- and prescription drug-related traffic crashes/fatalities Alcohol- and prescription drug-related emergency room visits Alcohol/ prescription drug poisonings Other (describe) ______________________________	Semi-annual Annual Every 2 years Other (describe) ____________________________________________________________________________________		Region County School Neighbor-hood Other (describe) ________________________________________________________________________	Race Ethnicity Gender Age Other (describe) ________________________________________________________________________	Middle school students High school students College students General population Other (describe) _____________________________________________________________________________________________________________________________________
2) (Fill in data source name here) ______	Dependence or abuse Educational disruptiona Alcohol- and prescription drug-related arrests Alcohol- and prescription drug-related traffic crashes/fatalities Alcohol- and prescription drug-related emergency room visits Alcohol and prescription drug poisonings Other (describe) ______________________________	Semi-annual Annual Every 2 years Other (describe) ____________________________________________________________________________________		Region County School Neighbor-hood Other (describe) ________________________________________________________________________	Race Ethnicity Gender Age Other (describe) ________________________________________________________________________	Middle school students High school students College students General population Other (describe) _____________________________________________________________________________________________________________________________________

^a Educational disruption is defined as substance abuse/use-related suspensions, expulsions, or both.

13. Local data sources for alcohol or prescription drug risk and protective factors^a (also known as intervening variables; do not include data provided directly by your State, tribal entity, or jurisdiction)^{B,F (autofill once completed initially)}

13a. Data source	13b. Related substance(s) (Select all that apply)	13c. Domain category (or categories) (Select all that apply)	13d. Variable category (or categories) (Select all that apply)	13e. Frequency of data collection (Select one response)	13f. Most recent data collection time point (Year)	13g. Geographic level(s) of data availability (Select all that apply)	13h. Subgroup level(s) of data availability (Select all that apply)	13gi. Respondents or population(s) (Select all that apply)
1) (Fill in data source name here) ______	Alcohol Prescription drugs Other (describe) ___________ ___________	Community School Family Peer/ Individual Other (describe) ____________________________________________________________	Perceived risk Parent/peer attitudes about use Communication with parents Parental monitoring Early initiation of substance use Involvement in prosocial activities Retail availability Retail promotion Social availability Law enforcement practices Social/ community norms Other (describe)______________	Semi-annual Annual Every 2 years Other (describe) ____________________________________________________________		Region County School Neighbor-hood Other (describe) __________ ____________________________________________________________	Race Ethnicity Gender Age Other (describe) ________________________________________________________________________________	Middle school students High school students College students General population Other (describe) ____________________________________________
2) (Fill in data source name here)______	Alcohol Prescription drugs Other (describe) ___________ ___________	Community School Family Peer/ Individual Other (describe) __________	Perceived risk Parent/peer attitudes about use Communication with parents Parental monitoring Early initiation of substance use Involvement in prosocial activities Retail availability Retail promotion Social availability Law enforcement practices Social/ community norms Other (describe)_____________	Semi-annual Annual Every 2 years Other (describe) __________ __________		Region County School Neighbor-hood Other (describe) __________ __________	Race Ethnicity Gender Age Other (describe) ____________________	Middle school students High school students College students General population Other (describe) ___________

^aNote. Risk and protective factors are predictive of problem behaviors. Risk factors are defined as community, school, family, peer or individual characteristics that increase the likelihood of substance use and other problem behaviors. Conversely, protective factors are community, school, family, peer or individual characteristics that reduce the likelihood of substance abuse and other problem behaviors.

^{14. For each of the types of data, indicate whether or not you used the data in conducting your community needs and resources assessment and whether or not it was provided to you by the SEOW. This would also include data that the SEOW showed you how to access or use. (Select one in each row.)A (autofill once completed initially)}

	Yes, the data were used and provided by the SEOW	Yes, the data were used but not provided by the SEOW	No, we did not use the data
14a. Student school survey data			
14b. School achievement data			
14c. Community surveys			
14d. Social norms data			
14e. Census data			
14f. Public health statistics (e.g., rates of mortality due to drug overdose)			
14g. Law enforcement data (e.g., drug arrests or drug trafficking)			
14h. Justice data (e.g., outcomes of criminal cases)			
14i. Public safety data (e.g., number of automobile accidents caused by drinking and driving)			
14j. Emergency room data related to underage drinking or prescription drug misuse			
14k. Prescription drug monitoring system data			
14l. Poison call center data related to alcohol or prescription drug use			
14m. Interviews or focus groups			
14n. Public meetings or forums (e.g., town hall meetings)			
14o. Other (Describe.)_________________			

Targeted PFS Needs

This set of questions asks about the specific targets your subrecipient community and your organization have identified for your SPF-PFS efforts. These targets may include specific consumption patterns, consequences, risk and protective factors (intervening variables), or subpopulations.

15. Indicate the consumption pattern(s) you are targeting for your SPF-PFS activities. (Select all that apply.)^{A (autofill once completed initially)}

• Have not identified a consumption pattern to target for your SPF-PFS activities

• Underage use of alcohol

• Underage binge drinking

• Nonmedical use of prescription drugs by youth age 12 to 17

• Nonmedical use of prescription drugs by young adults age 18 to 25

• Other consumption pattern (Describe.)

16. Indicate the consequence(s) you are targeting for your SPF-PFS activities. (Select all that apply.)^{A (autofill once completed initially)}

• Have not identified a consequence to target for your SPF-PFS activities

• Motor vehicle crashes

• Crime

• Hospitalizations or emergency room visits

• Poisonings (overdoses) by alcohol

• Poisonings (overdoses) by prescription drugs

• Alcohol-related illnesses and deaths

• Prescription drug-related illnesses and deaths

• Other consequences (Describe.) ________________________________________

17. Indicate the population(s) you will be targeting for your SPF-PFS substance abuse prevention activities. For this question, we would like to know if you have very specific groups of people at whom your prevention interventions will be aimed. For example, if you are delivering a prevention intervention to all middle schools in an area, then you would select only “middle school students”; you would not have to select all the possible race/ethnicity categories that might be enrolled in the schools. If, however, you are delivering a prevention intervention specifically designed to target high-school-age Latinos, then you would select Hispanic and high school students. (These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.)^{A (autofill once completed initially)}

• Have not identified a specific population to target for your SPF-PFS activities

• African American

• American Indian

• Alaska Native

• Asian/Pacific Islander (specify ethnic/national origin: ______________________)

• White

• Hispanic (specify ethnic/national origin: ______________________)

• Middle school students

• High school students

• College students

• Under 18

• Under 21

• Young adults age 18 to 25

• Parents

• Current or former military or military families

• Lesbian/gay/bisexual/transgender/questioning (LGBTQ)

• Individuals living in poverty

• Individuals whose native language is other than English

• Individuals with low literacy

• Individuals with mental illness

• Individuals with disabilities (e.g., hearing, visually, or physically impaired)

• Other target population (Describe.) _____________________________________

• Other target population (Describe.) _____________________________________

• Other target population (Describe.) _____________________________________

18. Indicate the intervening variable(s) you will be targeting for substance abuse prevention. (Select all that apply.)^{A (autofill once completed initially)}

• Have not yet selected an intervening variable to target

• Laws related to alcohol or prescription drugs

• Level of enforcement

• Social access (e.g., through friends or family members)

• Retail access

• Retail promotion (e.g., advertising, specials)

• Norms—perceived parent or peer attitudes or both

• Norms—perceived peer or friend use

• Perceived risk of harm

• Perceived risk of getting caught (e.g., by parents or law enforcement)

• Family communication around alcohol use or prescription drug misuse

• Resistance or life skills or both

• Availability of prosocial activities

• School policies

• Other intervening variable (Describe.) _____________________________________

• Other intervening variable (Describe.) _____________________________________

• Other intervening variable (Describe.)______________________________________

19. How would you describe the community or communities that you are targeting for your SPF-PFS substance abuse prevention activities? (Select all that apply.)^{A (autofill once completed initially)}

• 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

• Other (Describe.) _____________________________________________________

Section 2B. Capacity Building

In this section, we ask you about your activities related to capacity and capacity building. Capacity refers to the quality and level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF-PFS, capacity refers to the demonstrated ability of subrecipients to effectively implement each SPF step (e.g., implementation of evidence-based interventions) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model. Capacity building refers to activities conducted to improve the ability of an organization or community to deliver substance abuse prevention services, such as improving organizational resources, seeking and receiving relevant training and technical assistance (T/TA), building new relationships or strengthening existing relationships among groups and organizations involved in substance abuse prevention, and ensuring that prevention intervention activities and outcomes continue after SPF-PFS funding ends.

20. How would you rate the capacity of your organization in the following areas? (Note: At baseline, the questions should be answered with regard to your organization’s capacity at the time the PFS grant was awarded.) ^B,F

How much would you agree or disagree that your organization had/has enough capacity in each of the following areas to effectively implement their PFS interventions?	Strongly disagree	Disagree	Agree	Strongly agree
20a. Enough staff				
20b. Staff with the right skills				
20c. Enough fiscal/financial resources				
20d. Experience with the target populations				
20e. Experience with relevant prevention interventions				
20f. Experience collaborating with other organizations on relevant prevention interventions				
20g. Capability to sustain the prevention efforts over time				
20h. Capability to use data in prevention planning				
20i. Capability to use data in prevention evaluation				

Organizational Resources

This section collects information on the activities you conducted to improve organizational resources related to PFS, such as writing mission or vision statements, identifying goals and activities, hiring and training staff, identifying leaders, and obtaining physical space for the prevention intervention.

21. Have you conducted activities that produced gains in your organizational resources related to PFS during the past year? These could include such activities as identifying organizational goals, improving staff and resources, and coordinating data collection (Select one response.)^A

• Yes

• No (If selected, you will automatically proceed to Question 23.)

22. Indicate the activity or activities you conducted during the past Federal fiscal year that produced gains in your organizational resources related to PFS. (Select all that apply.)^A

• Wrote, reviewed, or rewrote organizational or coalition mission or vision statement

• Identified key organizational or coalition activities and goals

• Increased staffing

• Trained staff

• Identified coalition leaders

• Improved cultural competence

• Secured additional funding

• Secured physical space

• Coordinated or improved technical resources

• Coordinated or developed data collection or management information systems (MIS) or both

• Other: (Describe.)________________________________________________

Training and Technical Assistance

23. Select the area(s) in which you needed, requested, and/or received SPF-PFS-related guidance or training and technical assistance (T/TA) during the past Federal fiscal year. We are specifically asking about guidance and T/TA that contributed to your SPF-PFS activities. (Select all that apply.)^A

Training/technical assistance (T/TA) areas	Needed T/TA in this area	Requested T/TA in this area	Received T/TA in this area	Number of hours T/TA received in the past year
23a. Needs and resource assessment			
23b. Strategic plan development			
23c. Staff, task force, or coalition member training			
23d. Building relationships			
23e. Intervention selection			
23f. Participant recruitment			
23g. Intervention implementation			
23h. Intervention adaptation			
23i. Cultural competence			
23j. Health disparities			
23k. Evaluation			
23l. Sustainability			
23m. Other (Describe.) ______________________			
23n. Other (Describe.) ______________________			
23o. Other (Describe.) ______________________			

Relationship Building

This section collects information on partners you identified to join your SPF-PFS partnership or participate in planning and prevention intervention activities.

24. Have you identified key stakeholders, partners, and partner organizations to participate in your SPF-PFS planning and prevention intervention activities? (Select one response.)^A

• Yes

• No (If selected, you will automatically proceed to Question 26.)

25. Provide more information on the key stakeholders, partners, and partner organizations that participate in your organization’s SPF‑PFS activities. “Active” stakeholders/partners demonstrated support or participation in your activities and interventions during the past 6 months.^{E (autofill column 2 after initially completed)}

Sector	How many representatives from this sector are key stakeholders or partner members in your SPF-PFS activities?	How many of these key stakeholder or partner members were “active” during the past 6 months?	What was the average level of involvement for the members of this sector in your SPF-PFS activities during the past 6 months? (Mark only if # active partners >0)
			Low	Medium	High
25a. Youth groups/representatives					
25b. Schools/school districts					
25c. Other youth-serving organizations					
25d. Parents/family/caregiver groups					
25e. Tribal leaders or elders					
25f. Business community					
25g. Media (radio/TV stations; newspapers)					
25h. Clergy/faith-based organizations					
25i. Civic or volunteer organizations					
25j. Organizations serving LGBTQ individuals					
25k. Military					
25l. Law enforcement agencies					
25m. Courts/judiciary system					
25n. Substance abuse treatment organizations					
25o. Substance abuse prevention organizations					
25p. Health care professionals/agencies					
25q. Mental health professionals/agencies					
25r. Other State, local, or tribal government agencies					
25s. Other organizations (Describe.) __________					

Data Infrastructure

26. Which of the following local data-related resources are available for your PFS efforts? This may include resources that were developed through PFS as well as resources that existed before or were developed outside of PFS efforts.^B,F

	Does not exist or is not available to PFS	Available, but needs to be enhanced	Available and adequate
26a. A local database to house community, program, or participant data			
26b. Procedures for access to a State/jurisdiction/tribal grantee database			
26c. Expertise of local stakeholders in understanding and using data			
26d. Other (Describe.) ____________________ __________________________________			

27. How have you worked to develop or enhance data infrastructure needed for data-driven needs assessment, planning, and evaluation? (At baseline, this question refers to the time before you received PFS funding; at follow-up it refers to your PFS funding period. Select all that apply.)^B,F

• Not applicable; no work was done to enhance data infrastructure

• Developed or implemented a community-level survey data collection effort

• Developed or implemented a community-led qualitative data collection effort (e.g., interviews, focus groups)

• Developed or enhanced procedures for accessing data from other local agencies (e.g., criminal justice, education, child welfare, hospitals)

• Created or enhanced a local database to house community, program, or participant data

• Developed procedures for participation in a State/tribal/jurisdiction database

• Enhanced skills or expertise of local stakeholders in understanding and using data

• Developed procedures for utilizing data provided by the State/tribal entity/jurisdiction

• Other (Describe)____________________________________

Sustainability

This section asks about things you have done to ensure that prevention intervention activities and outcomes continue once SPF-PFS funding ends. These efforts might focus on ensuring continued funding, structures, networks, partnerships, leadership, and resources.

28. During the past Federal fiscal year, how have you worked to ensure that prevention intervention activities and outcomes continue after SPF-PFS funding has ended? (Select all that apply.)^A

• Not applicable; no work was done to ensure that prevention intervention activities and outcomes continue after SPF-PFS funding has ended.

• Leveraged, redirected, or realigned other funding sources or in-kind resources (e.g., used the success of the PFS efforts to secure other funds)

• Worked to ensure that prevention intervention activities are incorporated into the missions/goals and activities of other organizations (e.g., school districts, law enforcement agency)

• Worked to ensure that prevention staff positions are folded into other organizations (e.g., school districts, community agencies)

• Worked to gain formal adoption of prevention intervention activities into other organizations’ practices (e.g., school district curriculum, organizational policy change)

• Worked to implement local level laws, policies, or regulations to guarantee the continuation of prevention intervention activities or outcomes

• Worked on developing a partnership structure that will continue to function beyond the end of the PFS grant period

• Other (Describe.)____________________________________

Section 2C. Strategic Plan Development

This section collects information on the development of your SPF-PFS strategic plan, including what is addressed in the plan and who has contributed to the plan at the local level.

29. Did you complete a SPF-PFS strategic plan before receiving your PFS funding? (Select one response.)^B

• Yes

• No

30. Did you complete or substantially revise your completed SPF-PFS strategic plan during the past Federal fiscal year? If you are still working on a strategic plan, you will have the opportunity to report this information in a later reporting period. It is expected that at some point you will revisit your strategic plan. Reevaluating your strategic plan is part of the SPF and does not imply that you made mistakes in developing your original strategic plan. (Select one response.)^A

• Yes

• No, your PFS strategic plan was completed earlier, and you have not revised it in the past Federal fiscal year (If selected, you will automatically proceed to Question 32.)

• No, your PFS strategic plan has not been completed yet (If selected, you will automatically proceed to Question 32.)

31. Has your strategic plan been reviewed and approved by the agency responsible for the SPF‑PFS initiative in your State/tribal entity/jurisdiction? (Select one response.)^{A (answered only once unless revised)}

• Not applicable—your State/tribal entity/jurisdiction does not require or provide approval of the strategic plan

• Yes

• No

Section 2D. Prevention Intervention Implementation

This section collects information about the prevention interventions you selected for implementation in your community. A prevention intervention is an activity or set of activities to which a group or community is exposed to change their behavior. For SPF-PFS, these activities should aim to prevent or lower the rate of underage alcohol use, prescription drug misuse, and related problems. Interventions include activities related to community-based processes (e.g., holding meetings or training with community members, reallocating funds for prevention in the community, reorganizing local agencies and organizations to address substance abuse prevention), prevention education, alternative activities, problem identification and referral, environmental strategies (e.g., training of environmental influencers, policy change, enforcement), and information dissemination and other communication activities (e.g., raising community awareness, conducting social marketing campaigns). Refer to the Detailed Guidance for Reporting Prevention Interventions document for more information.

32. Did you or your community partners deliver any PFS-related prevention interventions during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 202)

Implemented Prevention Interventions

33. Name all the prevention interventions you or your community partners delivered during this reporting period as part of your SPF-PFS efforts. Refer to the Detailed Guidance for Reporting Prevention Interventions document before you complete the information in this section. This document will help you understand what to report as a prevention intervention in this section; which activities you should list as separate service types related to that intervention; and how to determine the appropriate CSAP strategy type, Institute of Medicine category, and so on.^{E (autofill for interventions previously reported, except for active/inactive status)}

You will need to complete a separate implementation information sub-form for each prevention intervention service type you name below that was active during the past 6 months. The CSAP strategy type will determine a subset of questions you must complete for the prevention intervention and service type.

33a. Intervention name	33b. Service type	33c. Service type name	33d. Date started	33e. CSAP strategy type	33f. Institute of Medicine (IOM) category	33g. Intervention targets	33h. Status	33i. Date completed or discontinued
From the drop-down menu, select the name of each prevention intervention you are implementing, or select “other” and write in the name	From the drop-down menu, select the service type for each major set of services or activities you are implementing under this prevention intervention, or select “other” and write in the name. Many strategies may consist of only one service type.	Write in the name of the specific set of services or activities that you implemented as part of your intervention if this name differs from the service type label	Date you began funding this intervention service type through your PFS initiative (MM/YYYY)	Select the CSAP strategy type that best describes this intervention service type: Community-based processes Prevention education Alternative activities Problem identification and referral Environmental strategy Information dissemination (and other communication activities)	Select the IOM category for this intervention service type: Universal direct Universal indirect Selective Indicated	Select the option that best describes the targets of this intervention sevice type: Individual young people Young people’s immediate social environments—family Young people’s immediate social environments—friends/peers Institutions or organizations that serve young people (e.g., schools, employers, health care providers) Whole communities Public laws or policy	Check whether the intervention service type was Active, Inactive, Completed, or Discontinued during the past 6 months	For intervention service types completed or discontinued during the past 6 months, indicate the date completed or discontinued (MM/YYYY)

Sample Table:

33a. Intervention name	33b. Service Type	33c. Service Type name	33d. Date started	33e. CSAP strategy type	33f. Institute of Medicine (IOM) category	33g. Intervention targets	33h. Status	33i. Date completed or discontinued
Communities Mobilizing for Change on Alcohol (CMCA)	Responsible beverage server training	Responsible beverage server training	02/2013	Environmental	Universal indirect	Institutions/ organizations	Active	NA
CMCA	Sobriety checkpoints	Sobriety checkpoints	05/2013	Environmental	Universal indirect	Community	Inactive	NA
All Stars	Prevention Education	All Stars	03/2013	Prevention education	Universal direct	Individual young people	Completed	07/2013
Smith University ATOD-free social events	ATOD-free social events	Smith University ATOD-free social events	02/2013	Alternative activities	Universal direct	Social environment—friends/peers	Active	NA
SADD Club	ATOD-free clubs	SADD Club	05/2013	Alternative activities	Universal direct	Individual young people	Inactive	NA

^{34. One of the goals of the PFS grant is to increase the number of prevention activities that are supported by collaboration and leveraging of funding streams. Describe the types of funding for substance abuse prevention you as the subrecipient organization received in the past Federal fiscal year (from October XXXX to September XXXX). The first column pertains to substance abuse prevention activities implemented by your organization as a whole, whereas the second and third columns refer specifically to the SPF-PFS prevention initiative. Do not include funding received by other organizations in your coalition or group, unless those funds are used for PFS activities. A}

Source of funding/resources	Total dollar amount that went to substance use prevention for your organization as a whole ($)	Is any part of this funding stream used for PFS activities? (YES/NO)	Amount of this funding stream used for PFS activities ($)
34a. SPF-PFS	$	Yes No	$
34b. Drug-Free Communities (DFC) grant	$	Yes No	$
34c. Sober Truth on Preventing Underage Drinking (STOP) Act funding	$	Yes No	$
34d. Minority HIV/AIDS Initiative (MAI HIV)	$	Yes No	$
34e. Substance Abuse Prevention and Treatment Block Grant	$	Yes No	$
34f. Medicaid (Federal, State, local)	$	Yes No	$
34g. Other Federal funds (Describe.) ____________________________	$	Yes No	$
34h. Other State/tribal/jurisdiction funds (Describe.) ____________________________	$	Yes No	$
34i. Other local government funds (Describe.) ____________________________	$	Yes No	$
34j. Foundations/nonprofit organizations	$	Yes No	$
34k. Corporate/business entities	$	Yes No	$
34l. Individual donations/funding from fundraising events	$	Yes No	$
34m. Other (Specify.) _________________________________	$	Yes No	$

Prevention Intervention Information

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

35a. What specific consumption pattern(s) or consequence(s) (or both) are the prevention intervention intended to target? (Select all that apply.)^{E (autofill after first completed)}

• Underage use of alcohol

• Underage binge drinking

• Nonmedical use of prescription drugs by youth age 12 to 17

• Nonmedical use of prescription drugs by young adults age 18 to 25

• Motor vehicle crashes

• Crime

• Alcohol-related illnesses and deaths

• Prescription drug-related illnesses and deaths

• Hospitalizations or emergency room visits

• Poisonings (overdoses) of alcohol or prescription drugs

• Other consumption pattern or consequence (Describe.)

• Other consumption pattern or consequence (Describe.)

35b. What specific intervening variable(s) is the prevention intervention intended to target? (Select all that apply.)^{E (autofill after first completed)}

• Have not yet selected an intervening variable to target

• Laws related to alcohol or prescription drugs

• Level of enforcement

• Social access

• Retail access

• Retail promotion

• Norms—perceived parent or peer attitudes or both

• Norms—perceived peer use

• Perceived risk of harm

• Perceived risk of getting caught

• Family communication around alcohol use or prescription drug misuse

• Resistance or life skills or both

• Availability of prosocial activities

• School policies

• Other intervening variable (Describe.)

35c. Which factors did you consider when choosing this prevention intervention? (Select all that apply.) ^{E (autofill after first completed)}

• It matched your target outcome(s)

• It matched your target intervening variable(s)

• It addressed your specific target population(s)

• It is culturally responsive to community needs

• You perceive community support for it

• You perceive that it will be easy to implement

• You have used this intervention in the past

• The intervention designer will provide training and technical assistance

• Its cost meets your needs

• You see strength of evidence that the intervention is effective in changing your target outcome(s)

• You see strength of evidence that the intervention is effective in changing your target intervening variable(s)

• The intervention was recommended by your State, tribal entity, or jurisdiction

• Other (Describe.) _______________________________________

36a. Is this an evidence-based program, policy, or practice? (Select one response.)^{E (autofill after first completed)}

• Yes

• No (If selected, you will automatically proceed to Question 37.)

• I don’t know (If selected, you will automatically proceed to Question 37.)

36b. How do you know this is an evidence-based program, policy, or practice? (Select all that apply.)^{E (autofill after first completed)}

• We did not use any specific criteria to determine that this was an evidence-based program, policy, or practice

• Inclusion in a Federal registry of evidence-based interventions

• Found to be effective (on the primary targeted outcome) in a published, scientific journal

• Based on a theory of change that is documented in a clear logic or conceptual model

• Similar in content and structure to interventions that appear in registries or peer-reviewed literature

• Supported by documentation of effective implementation multiple times in the past (showing consistent pattern of positive effects)

• Reviewed by a panel of informed experts including qualified prevention researchers, local prevention practitioners, and key community leaders (e.g., law enforcement and education representatives, elders within indigenous cultures)

• Appeared on a list of recommended evidence-based programs, policies, and practices provided by our State, tribal entity, or jurisdiction.

• Other (Describe.)

36c. Have you renamed the existing evidence-based program, policy, or practice to implement it in your community? (Select one response.)^{E (autofill after first completed)}

• Yes (Provide the original name.)

• No

37. Which of the following best describes the implementation history of this prevention intervention in your community? (Select one response.)^{E (autofill after first completed)}

• Not implemented in the community before PFS funding

• Continuation of a SPF SIG prevention intervention

• Continuation of a non-SPF SIG prevention intervention

38. Does this prevention intervention include a curriculum or manual? By curriculum or manual, we mean a set of instructions about how to deliver the prevention intervention. This can be a preexisting curriculum or manual created by the prevention intervention developer or a formal curriculum or manual developed by the community partner. This applies to all types of interventions from environmental strategies with a formal set of core activities to prevention education interventions with formal curricula. (Select one response.)^{E (autofill after first completed)}

• Yes

• No

• I don’t know

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

39. For Questions 39a through 39g, indicate the locations and target population being served by this prevention intervention service type. You are required to include ZIP codes (Question 39c) for all locations being served by this prevention intervention service type. If your target population is the entire county, you may enter “county-wide” for Question 39c. If you are implementing in separate settings (e.g., schools, workplaces), list each setting separately. This is for purposes of reporting to CSAP.

Use one line to describe each location served by the intervention service type. Other than ZIP code and estimated target population (Question 39g), you need to complete only those categories that are appropriate for this prevention intervention service type and community served.^{E (autofill after first completed)}

	39a. Location (e.g., school name, business, community center)	39b. City/town	39c. County/ parish	39d. ZIP codes	39e. Other geographic descriptor (e.g., neighborhood, development) Describe—500-character limit	39f. Target population description Describe—500-character limit	39g. What is the estimated target population number within the area described?a
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

^aThe target population of the intervention strategy is likely smaller than the total population in the community. For example, if 10,000 individuals live in the area (total population), but only 3,000 of those are in the target 12- to 20-year-old age group for this prevention intervention strategy, your estimated target population is 3,000. If your target population for this prevention intervention strategy is more specific (e.g., Hispanic high school students or non-college youth age 18 to 20), your target population number would be even smaller (e.g., 200). Report your target population size as accurately as possible.

40. How many of your key stakeholders, partners, and partner organizations supported or partnered with you on this prevention intervention service type during the past 6 months? Indicate the number or organizations and number of individuals who partnered with you on this prevention intervention service type from each sector.^E

40a. Sectora	40b. Number of organizations	40c. Number of individuals

^aSectors will be prepopulated in this table on the basis of responses to Question 25.

41a. Did your organization leverage funding or resources to support implementation of this prevention intervention service type (i.e., use resources or funding not directly supported or provided by your SPF-PFS funding to partially support your implementation)?^E

• Yes

• No (If selected, you will automatically proceed to Question 42.)

• I don’t know (If selected, you will automatically proceed to Question 42.)

41b. Which of your organization’s other substance use prevention funding sources or resources supported implementation of this prevention intervention service type? (Select all that apply.)^{E (autofill after first completed)}

[LIST HERE OF FUNDING SOURCES/RESOURCES INDICATED IN QUESTION 34 ALONG WITH AN “OTHER” RESPONSE OPTION]

42. Approximately what percentage of total funding for this prevention intervention service type comes from SPF-PFS funds? If you do not know the exact amount allocated, respond with your best estimate. This response should be written as a whole number. For example, if you received about a third of your funding for this prevention intervention service type from SPF SIG funds, respond with 33.^{A(autofill after first completed)}

%

Community-Based Processes Sub-Form

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

43. Did you do any work related to community-based processes (e.g., stakeholder/partner meetings, T/TA for community, reorganization of local agencies, or reallocation of community prevention funds) during the past 6 months?^E

• Yes

• No (If selected, you will automatically proceed to the end of this sub-form.)

44. Indicate the number of stakeholder/partner meetings you held during the past 6 months, if any. This response should be written as a whole number (e.g., 4).^E

Meetings (If none, enter ‘0.’)

45. Indicate the number of stakeholders/partners you trained during the past 6 months, if any. This response should be written as a whole number (e.g., 4).^E

Stakeholders/partners trained (If none, enter “0.”)

46. Indicate the number of community members, other than stakeholders/partners, you trained during the past 6 months, if any. This response should be written as a whole number (e.g., 4).^E

Community members trained (If none, enter “0.”)

47. Indicate the number of community organizations to whom you provided training or technical assistance during the past 6 months, if any. This response should be written as a whole number (e.g., 4).^E

Community organizations (If none, enter “0.”)

48. Did you develop a prevention provider network during the past 6 months? (Select one response.)^E

• Yes

• No

49. Did you help with reorganizing local agencies to promote efficiency in delivering substance abuse prevention during the past 6 months? (Select one response.)^E

• Yes

• No

50. Did you reallocate local funds for substance abuse prevention during the past 6 months? (Select one response.)^E

• Yes

• No

51. Did you formally change the ways local organizations work together to address substance abuse prevention during the past 6 months—for example, by officially changing school curricula or by documenting specific policies or practices for working together? (Select one response.)^E

• Yes

• No

52. Did you conduct other community activities during this reporting period? (Select one response.)^E

• Yes (Describe) ______________________________________________________

• No

Questions 53 through 57 collect information on the individuals reached through the community-based processes activities within your PFS efforts (reported in Questions 43 through 52).

53a. Estimate the total number of individuals who were reached or affected by your community-based processes activities during the past 6 months. The number reached goes beyond the individual community members who participated in these activities to the community members impacted by the related changes. If you are unsure of the exact number of individuals affected, respond with your best estimate.^E

__________ total individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

53b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those who received or were affected by your community-based processes activities, how many were new to this second half of the Federal fiscal year? If you are unsure of the exact number of new individuals reached, respond with your best estimate. New individuals are those who had not been reached or affected by your community-based partnership activities or counted in the first half of the year. Note that the number reported in Question 53b will always be smaller than or equal to the number reported in Question 53a.^E

__________ new individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

54. Of the total number of (new) participants who were reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), estimate how many were male and how many were female. The number of females, males, and unknown should add up to the total of participants reported in Question 53a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

54a. Number of females: _____________

54b. Number of males: ______________

54c. Gender unknown: ______________

55. Of the total number of (new) participants were reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 53a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

55a. Children age 0 to 11: _____________

55b. Youth age 12 to 17: _____________

55c. Young adults age 18 to 20: _____________

55d. Young adults age 21 to 25: ______________

55e. Adults age 26 and older: _____________

55f. Age unknown: ___________

56. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, White, multiracial, other, and unknown should add up to the total of participants reported in Question 53a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

56a. American Indian or Alaska Native: _____________

56b. Black or African American: _____________

56c. White: _____________

56d. Asian: _____________

56di. Asian Indian: _______________

56dii. Chinese: __________________

56diii. Filipino: __________________

56div. Japanese: ________________

56dv. Korean: ___________________

56dvi. Vietnamese: _______________

56dvii. Other Asian: _______________

56e. Native Hawaiian or Other Pacific Islander: ______________

56ei. Native Hawaiian: _______________

56eii. Guamanian or Chamorro: _______________

56eiii. Samoan: __________________

56eiv. Other Pacific Islander: __________________

56f. Multiracial: ___________

56g. Other: _____________

56h. Race unknown: ___________

57. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 53a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

57a. Hispanic, Latino/a, or of Spanish origin: ____________

57ai. Mexican, Mexican American, Chicano/a: _____________

57aii. Puerto Rican: ______________________

57aiii. Cuban: ________________________

57aiv. Other Hispanic, Latino, or Spanish origin: ________________

57b. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

57c. Hispanic ethnicity unknown: ____________

58a. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), estimate how many speak English at each of the levels indicated below. The number speaking English very well, well, not well, not at all, and unknown should add up to the total number of participants reported in Question 53a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

58ai. Very well: _____________

58aii. Well: _____________

58aiii. Not well: _____________

58aiv. Not at all: ___________

58av. English language ability unknown: _________________

58b. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), estimate how many speak any of the languages below as their primary language at home. The number of English speakers, Spanish speakers, other language speakers, and unknown should add up to the total of participants reported in Question 53a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

58bi. English: _____________

58bii. Spanish: _____________

58biii. Other language: _____________

58biv. Language unknown: ___________

59. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), estimate how many have any of the following disabilities. In this case, the total number of respondents with the disabilities below may be higher or lower than the total of participants reported in Question 53a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

59a. Deaf or difficulty hearing: _____________

59b. Blind or difficulty seeing (even with glasses): _____________

59c. Serious difficulty walking or climbing stairs: ___________

59d. Difficulty dressing or bathing: _____________

59e. Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition: _____________

59f. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition: _____________

59g. Disability status unknown: ___________

60. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), estimate how many currently serve in the military. The number of current Armed Forces, Reserves, and National Guard service members, along with the former members, nonmembers, and unknown, should add up to the total of participants reported in Question 53a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

60a. Currently serve in the Armed Forces: _____________

60b. Currently serve in the Reserves: _____________

60c. Currently serve in the National Guard: _____________

60d. Served in the past, but do not currently serve in the Armed Forces, Reserves, or National Guard: _________

60e. Never served in the Armed Forces, Reserves, or National Guard: _________

60f. Military status unknown: ___________

61. Of the total number of (new) participants reached or affected by your community-based processes activities during the past 6 months (reported in Question 53a/b), estimate how many are family members of active duty or separated/retired Armed Forces, Reserves, and National Guard service members. The number of family members of active duty and separated/retired Armed Forces, Reserves, and National Guard service members, along with the nonfamily members and unknown, should add up to the total of participants reported in Question 53a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

61a. Family member of someone on active duty in the Armed Forces, Reserves, or National Guard: ______

61b. Family member of someone separated or retired from the Armed Forces, Reserves, or National Guard: ______

61c. Not a family member of someone on active duty in, separated from, or retired from the Armed Forces, Reserves, or National Guard: _____________

61d. Military family member status unknown: ___________

Prevention Education Sub-Form

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

62. When did you first start serving participants with this Prevention Education intervention for your PFS initiative, including all cycles? (Provide MM/YYYY.)^{E (autofill after first completed)}

_______________________ MM/YYYY

63. Is this a recurring prevention intervention, in which the same group of people are served over multiple sessions? An example would be a prevention intervention that is delivered to the same group of participants every Monday night for 6 weeks, or to an 8th-grade health class every Friday in a semester. (Select one response.)^{E (autofill after first completed)}

• Yes

• No

64. Is this prevention intervention implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year? If your prevention intervention takes place for a period of time with the same participants and then starts over with new participants, select “yes.” A prevention intervention strategy can be both recurring and implemented in a series of cycles. (Select one response.)^{E (autofill after first completed)}

• Yes

• No

65. What was/were the format(s) of the prevention education intervention during the past Federal fiscal year? (Select all that apply.)^A

• Individual

• Small group (2–9)

• Large group (10–49)

• Extra-large group (50+)

• Web-based

• Other (Describe.) ______________________________________________________

66. Indicate the type(s) of participants served by this prevention education intervention during the past Federal fiscal year.^A

66a. Age group(s) targeted for service during the past 6 months: (Select all that apply.)

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Young adults age 21 to 25

• Adults age 26 or older

• Other (Describe.) _____________________________________________________

66b. Population type(s) targeted for service during the past 6 months: (Select all that apply.)

• Middle school students

• High school students

• College students

• Parents

• Health care providers

• Employees (i.e., recipients of a workplace substance abuse prevention program)

• Current or former military members

• Military family members

• Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

• Individuals living in poverty

• Individuals whose native language is other than English

• Individuals with low literacy

• Individuals with mental illness

• Individuals with disabilities (e.g., hearing, visually, or physically impaired)

• Other (Describe.) ________________________________________________________

67. In the table below, list each separate location where you implemented this prevention education intervention and then indicate how many groups of participants started the prevention education intervention during the past 6 months and how many groups completed the prevention education intervention during the past 6 months. Do not include groups who started and completed in previous reporting periods. Count each group in the location separately (e.g., count each classroom in each school). The number of groups should be written as a whole number (e.g., 4).^E

67a. Location (e.g., Wade Middle School)	67b. Number of groups started in the past 6 months	67c. Number of groups completed in the past 6 months

68a. What was the average number of sessions provided for all groups of participants in the prevention education intervention during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).^A

sessions

68b. What was the average length of the individual sessions, in hours, during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).^A

hours

69a. How many total participants were served by this prevention education intervention during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ participants (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

69b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those who were served by the prevention education intervention during the past 6 months, how many were new participants this second half of the Federal fiscal year? New participants are participants who had not received or participated in the prevention intervention before and were therefore not counted in the first 6 months of the year. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4), and the number reported in 69b will always be smaller than or equal to the number reported in 69a.^E

__________ new participants (If none, enter “0”—if it is a second half of the year report, you will automatically proceed to the end of this sub-form.)

70. Of the total number of (new) participants served by this prevention education intervention during the past 6 months (reported in Question 69a/b), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of participants reported in Question 69a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

70a. Number of females: _____________

70b. Number of males: ______________

70c. Gender unknown: ______________

71. Of the total number of (new) participants served by this prevention education intervention during the past 6 months (reported in Question 69a/b), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 69a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

71a. Children age 0 to 11: _____________

71b. Youth age 12 to 17: _____________

71c. Young adults age 18 to 20: _____________

71d. Young adults age 21 to 25: ______________

71e. Adults age 26 and older: _____________

71f. Age unknown: ___________

72. Of the total number of (new) participants served by this prevention education intervention during the past 6 months (reported in Question 69a/b), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, White, multiracial, other, and unknown should add up to the total of participants reported in Question 69a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

72a. American Indian or Alaska Native: _____________

72b. Black or African American: _____________

72c. White: _____________

72d. Asian: _____________

72di. Asian Indian: _______________

72dii. Chinese: __________________

72diii. Filipino: __________________

72div. Japanese: ________________

72dv. Korean: ___________________

72dvi. Vietnamese: _______________

72dvii. Other Asian: _______________

72e. Native Hawaiian or Other Pacific Islander: ______________

72ei. Native Hawaiian: _______________

72eii. Guamanian or Chamorro: _______________

72eiii. Samoan: __________________

72eiv. Other Pacific Islander: __________________

72f. Multiracial: ___________

72g. Other: _____________

72h. Race unknown: ___________

73. Of the total number of (new) participants served by this prevention education intervention during the past 6 months (reported in Question 69a/b), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 69a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

73a. Hispanic, Latino/a, or of Spanish origin: ____________

73ai. Mexican, Mexican American, Chicano/a: _____________

73aii. Puerto Rican: ______________________

73aiii. Cuban: ________________________

73aiv. Other Hispanic, Latino, or Spanish origin: ________________

73b. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

73c. Hispanic ethnicity unknown: ____________

74a. Of the total number of (new) participants served by this prevention education intervention during the past 6 months (reported in Question 69a/b), estimate how many speak English at each of the levels indicated below. The number speaking English very well, well, not well, not at all, and unknown should add up to the total number of participants reported in Question 69a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

74ai. Very well: _____________

74aii. Well: _____________

74aiii. Not well: _____________

74aiv. Not at all: ___________

74av. English language ability unknown: _________________

74b. Of the total number of (new) participants served by this prevention education intervention during the past 6 months (reported in Question 69a/b), estimate how many speak any of the languages below as the primary language at home. The number of English speakers, Spanish speakers, other language speakers, and unknown should add up to the total of participants reported in Question 69a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

74bi. English: _____________

74bii. Spanish: _____________

74biii. Other language: _____________

74biv. Language unknown: ___________

75. Of the total number of (new) participants served by this prevention intervention during the past 6 months (reported in Question 69a/b), estimate how many have any of the following disabilities. In this case, the total number of respondents with the disabilities below may be higher or lower than the total of participants reported in Question 69a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

75a. Deaf or difficulty hearing: _____________

75b. Blind or difficulty seeing (even with glasses): _____________

75c. Serious difficulty walking or climbing stairs: ___________

75d. Difficulty dressing or bathing: _____________

75e. Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition: _____________

75f. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition: _____________

75g. Disability status unknown: ___________

76. Of the total number of (new) participants served by this prevention intervention during the past 6 months (reported in Question 69a/b), estimate how many currently serve in the military. The number of current Armed Forces, Reserves, and National Guard service members, along with the former members, nonmembers, and unknown, should add up to the total of participants reported in Question 69a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

76a. Currently serve in the Armed Forces: _____________

76b. Currently serve in the Reserves: _____________

76c. Currently serve in the National Guard: _____________

76d. Served in the past, but do not currently serve in the Armed Forces, Reserves, or National Guard: _________

76e. Never served in the Armed Forces, Reserves, or National Guard: _________

76f. Military status unknown: ___________

77. Of the total number of (new) participants served by this prevention intervention during the past 6 months (reported in Question 69a/b), estimate how many are family members of active duty or separated/retired Armed Forces, Reserves, and National Guard service members. The number of family members of active duty and separated/retired Armed Forces, Reserves, and National Guard service members, along with the nonfamily members and unknown, should add up to the total of participants reported in Question 69a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

77a. Family member of someone on active duty in the Armed Forces, Reserves, or National Guard: ______

77b. Family member of someone separated or retired from the Armed Forces, Reserves, or National Guard: ______

77c. Not a family member of someone on active duty in, separated from, or retired from the Armed Forces, Reserves, or National Guard: _____________

77d. Military family member status unknown: ___________

Alternative Drug-Free Activities Sub-Form

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

78. When did you first start serving participants with this Alternative Drug-Free Activities prevention intervention for your PFS initiative, including all cycles? (Provide MM/YYYY.) ^{E (autofill after first completed)}

_____________________ MM/YYYY

79. Indicate the type(s) of participants served by alternative drug-free activities during the past Federal fiscal year. ^A

79a. Age group(s) targeted for service during the past 6 months: (Select all that apply.)

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Young adults age 21 to 25

• Adults age 26 or older

• Other (Describe.) ______________________________________________________

79b. Population type(s) targeted for service during the past 6 months: (Select all that apply.)

• Middle school students

• High school students

• College students

• Parents

• Health care providers

• Employees (i.e., recipients of a workplace substance abuse prevention program)

• Current or former military members

• Military family members

• Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

• Individuals living in poverty

• Individuals whose native language is other than English

• Individuals with low literacy

• Individuals with mental illness

• Individuals with disabilities (e.g., hearing, visually, or physically impaired)

• Other (Describe.) ____________________________________________________

80. Are the alternative activities targeted at identifiable participants (as in student clubs, mentoring), or with events for populations as a whole (as in drug-free events, festivals/fairs, drop-in activities? (Select all that apply.)^E

• Identifiable participants (If selected, you will complete Questions 84–87.)

• Populations as a whole (If selected, you will complete Questions 88–98.)

81. Are these recurring activities, in which roughly the same group of people is served over multiple sessions? (Select one response.)^{E (autofill after first completed)}

• Yes

• No

82. Are the alternative drug-free activities implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year? If your prevention intervention takes place for a period of time with the same participants and then starts over with new participants, select “yes.” A prevention intervention strategy can be both recurring and implemented in a series of cycles. (Select one response.)^{E (autofill after first completed)}

• Yes

• No

83. What was/were the format(s) of the alternative drug-free activities during the past Federal fiscal year? (Select all that apply.)^A

• Individual

• Small group (2–9)

• Large group (10–49)

• Extra-large group (50+)

• Web-based

• Other (Describe.) ________________________________________________________

Questions for alternative activities targeted at identifiable participants

84. In the table below, list each separate location where you implemented these alternative drug-free activities and then indicate how many groups of participants started the alternative drug-free activities during the past 6 months and how many groups completed the alternative drug-free activities during the past 6 months. Do not include groups who started and completed in previous reporting periods. Count each group in the location separately (e.g., count each classroom in each school). The number of groups should be written as a whole number (e.g., 4).^E

84a. Location (e.g., Wade Middle School)	84b. Number of groups started in the past 6 months	84c. Number of groups completed in the past 6 months

85. What was the average number of sessions provided for all groups of participants in the alternative drug-free activities during the past 6 months? This response should be written as a whole number (e.g., 4).^E

_______________________ sessions

86. What was the total number of hours provided for all groups of participants in the alternative drug-free activities during the past 6 months? This response should be written as a whole number (e.g., 4).^E

hours

Questions for alternative activities delivered to populations as a whole, not identifiable participants

87. What type(s) of the alternative activities events that were not targeted to identifiable participants did you implement during the past 6 months? (Select all that apply.)^E

• Concert

• Festival or fair

• Sporting event

• Picnic

• Drop-in activity

• Web-based gathering

• Other (Describe.)

88. How many separate alternative activities events that were not targeted to identifiable participants were conducted during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ events

89a. How many total participants were served or reached by the alternative drug-free activities during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ participants (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

89b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those who were served or reached by the alternative drug-free activities during the past 6 months, how many were new participants this second half of the Federal fiscal year? New participants are participants who had not received or participated in the prevention intervention before and were therefore not counted in the first 6 months of the year. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4), and the number reported in Question 89b will always be smaller than or equal to the number reported in Question 89a.^E

_____________ new participants (If none, enter “0”—if it is the second half report, you will automatically proceed to the end of this sub-form.)

90. Of the total number of (new) participants served or reached by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total number of participants reported in Question 89a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

90a. Number of females: _____________

90b. Number of males: ______________

90c. Gender unknown: _______________

91. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 89a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

91a. Children age 0 to 11: _____________

91b. Youth age 12 to 17: _____________

91c. Young adults age 18 to 20: _____________

91d. Young adults age 21 to 25: ______________

91e. Adults age 26 and older: _____________

91f. Age unknown: _____________

92. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, White, multiracial, other, and unknown should add up to the total of participants reported in Question 89a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

92a. American Indian or Alaska Native: _____________

92b. Black or African American: _____________

92c. White: _____________

92d. Asian: _____________

92di. Asian Indian: _______________

92dii. Chinese: __________________

92diii. Filipino: __________________

92div. Japanese: ________________

92dv. Korean: ___________________

92dvi. Vietnamese: _______________

92dvii. Other Asian: _______________

92e. Native Hawaiian or Other Pacific Islander: ______________

92ei. Native Hawaiian: _______________

92eii. Guamanian or Chamorro: _______________

92eiii. Samoan: __________________

92eiv. Other Pacific Islander: __________________

92f. Multiracial: ___________

92g. Other: _____________

92h. Race unknown: ___________

93. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 89a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

93a. Hispanic, Latino/a, or of Spanish origin: ____________

93ai. Mexican, Mexican American, Chicano/a: _____________

93aii. Puerto Rican: ______________________

93aiii. Cuban: ________________________

93aiv. Other Hispanic, Latino, or Spanish origin: ________________

93b. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

93c. Hispanic ethnicity unknown: ____________

94a. Of the total number of (new) participants served by your alternative drug-free activities during the past 6 months (reported in Question 89a/b), estimate how many speak English at each of the levels indicated below. The number speaking English very well, well, not well, not at all, and unknown should add up to the total number of participants reported in Question 89a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

94ai. Very well: _____________

94aii. Well: _____________

94aiii. Not well: _____________

94aiv. Not at all: ___________

94av. English language ability unknown: _________________

94b. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), estimate how many speak any of the languages below as the primary language at home. The number of English speakers, Spanish speakers, other language speakers, and unknown should add up to the total of participants reported in Question 89a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

94bi. English: _____________

94bii. Spanish: _____________

94biii. Other language: _____________

94biv. Language unknown: ___________

95. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), estimate how many have any of the following disabilities. In this case, the total number of respondents with the disabilities below may be higher or lower than the total of participants reported in Question 89a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

95a. Deaf or difficulty hearing: _____________

95b. Blind or difficulty seeing (even with glasses): _____________

95c. Serious difficulty walking or climbing stairs: ___________

95d. Difficulty dressing or bathing: _____________

95e. Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition: _____________

95f. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition: _____________

95g. Disability status unknown: ___________

96. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), estimate how many currently serve in the military. The number of current Armed Forces, Reserves, and National Guard service members, along with the former members, nonmembers, and unknown, should add up to the total of participants reported in Question 89a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

96a. Currently serve in the Armed Forces: _____________

96b. Currently serve in the Reserves: _____________

96c. Currently serve in the National Guard: _____________

96d. Served in the past, but do not currently serve in the Armed Forces, Reserves, or National Guard: _________

96e. Never served in the Armed Forces, Reserves, or National Guard: _________

96f. Military status unknown: ___________

97. Of the total number of (new) participants served by the alternative drug-free activities during the past 6 months (reported in Question 89a/b), estimate how many are family members of active duty or separated/retired Armed Forces, Reserves, and National Guard service members. The number of family members of active duty and separated/retired Armed Forces, Reserves, and National Guard service members, along with the nonfamily members and unknown, should add up to the total of participants reported in Question 89a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

97a. Family member of someone on active duty in the Armed Forces, Reserves, or National Guard: ______

97b. Family member of someone separated or retired from the Armed Forces, Reserves, or National Guard: ______

97c. Not a family member of someone on active duty in, separated from, or retired from the Armed Forces, Reserves, or National Guard: _____________

97d. Military family member status unknown: ___________

Problem Identification and Referral Sub-Form

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

98. When did you first start serving participants with this Problem Identification and Referral prevention intervention, including all cycles? (Provide MM//YYYY.)^{E (autofill after first completed)}

_________ MM//YYYY

99. Indicate the type(s) of participants served by this Problem Identification and Referral prevention intervention during the past Federal fiscal year. ^A

99a. Age group(s) targeted for service during the past 6 months: (Select all that apply.)

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Young adults age 21 to 25

• Adults age 26 or older

• Other (Describe.)

99b. Population type(s) targeted for service during the past 6 months: (Select all that apply.)

• Middle school students

• High school students

• College students

• Parents

• Health care providers

• Employees (i.e., recipients of a workplace substance abuse prevention program)

• Current or former military members

• Military family members

• Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

• Individuals living in poverty

• Individuals whose native language is other than English

• Individuals with low literacy

• Individuals with mental illness

• Individuals with disabilities (e.g., hearing, visually, or physically impaired)

• Other (Describe.)

100. Where did this problem identification and referral activity take place during the past Federal fiscal year? (Select all that apply.)^A

• School

• Health care facilities

• Jails or prisons

• Courts

• Workplace or workplace program

• Other (Describe.)

101. At how many different places did this problem identification and referral activity occur during the past 6 months? How many different cycles of this activity did you implement at each location? List each separate organization or location where problem identification and referral activities occurred as a separate place (e.g., list each separate school, health care facility, and so on). Then indicate the number of cycles in which you implemented this activity at each location, if applicable. If the activity is ongoing and does not occur in distinct cycles, indicate not applicable (NA). ^E

	101a. Organization or location	101b. Number of cycles (or NA)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

102. What type(s) of services were individuals referred to during the past 6 months? (Select all that apply.)^E

• Substance abuse treatment

• Mental health treatment

• Substance abuse prevention activities

• Housing services

• After-school activities

• Transportation

• Day care or adult care services

• Health care

• Other (Describe.)

103a. What was the total number of individuals for whom problem identification and referral services were provided during the past 6 months? This response should be written as a whole number (e.g., 4).^E

_________ individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

103b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those who were provided problem identification and referral services during the past 6 months, how many were new participants this second half of the Federal fiscal year? New participants are participants who had not received or participated in the prevention intervention before and were therefore not previously counted in the first 6 months of the year. If you are unsure of the exact number of new participants, respond with your best estimate. This response should be written as a whole number (e.g., 4), and the number reported in Question 103b will always be smaller than or equal to the number reported in Question 103a.^E

_____________ new participants (If none, enter “0”—for the second half of the year report, you will automatically proceed to the end of this sub-form.)

104. Of the total number of (new) participants provided problem identification and referral services during the past 6 months (reported in Question 103a/b), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of participants reported in Question 103a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

104a. Number of females: _____________

104b. Number of males: ______________

104c. Number gender unknown: _______________

105. Of the total number of (new) participants provided problem identification and referral services during the past 6 months (reported in Question 103a/b), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in Question 103a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

105a. Children age 0 to 11: _____________

105b. Youth age 12 to 17: _____________

105c. Young adults age 18 to 20: _____________

105d. Young adults age 21 to 25: ______________

105e. Adults age 26 and older: _____________

105f. Age unknown: ______________

106. Of the total number of (new) participants provided problem identification and referral services during the past 6 months (reported in Question 103a/b), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, White, multiracial, other, and unknown should add up to the total of participants reported in Question 103a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

106a. American Indian or Alaska Native: _____________

106b. Black or African American: _____________

106c. White: _____________

106d. Asian: _____________

106di. Asian Indian: _______________

106dii. Chinese: __________________

106diii. Filipino: __________________

106div. Japanese: ________________

106dv. Korean: ___________________

106dvi. Vietnamese: _______________

106dvii. Other Asian: _______________

106e. Native Hawaiian or Other Pacific Islander: ______________

106ei. Native Hawaiian: _______________

106eii. Guamanian or Chamorro: _______________

106eiii. Samoan: __________________

106eiv. Other Pacific Islander: __________________

106f. Multiracial: ___________

106g. Other: _____________

106h. Race unknown: ___________

107. Of the total number of (new) participants provided problem identification and referral services during the past 6 months (reported in Question 103a/b), indicate how many were Hispanic, Latino/a, or of Spanish original and how many were not. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 103a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

107a. Hispanic, Latino/a, or of Spanish origin: ____________

107ai. Mexican, Mexican American, Chicano/a: _____________

107aii. Puerto Rican: ______________________

107aiii. Cuban: ________________________

107aiv. Other Hispanic, Latino, or Spanish origin: ________________

107b. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

107c. Hispanic ethnicity unknown: ____________

108a. Of the total number of (new) participants provided problem identification and referral services during the past 6 months (reported in Question 103a/b), estimate how many speak English at each of the levels indicated below. The number speaking English very well, well, not well, not at all, and unknown should add up to the total number of participants reported in Question 103a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

108ai. Very well: _____________

108aii. Well: _____________

108aiii. Not well: _____________

109aiv. Not at all: ___________

108av. English language ability unknown: _________________

108b. Of the total number of (new) participants provided problem identification and referral services during the past 6 months (reported in Question 103a/b), estimate how many speak any of the languages below as the primary language at home. The number of English speakers, Spanish speakers, other language speakers, and unknown should add up to the total of participants reported in Question 103a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

108bi. English: _____________

108bii. Spanish: _____________

108biii. Other language: _____________

108biv. Language unknown: ___________

109. Of the total number of (new) participants served by your problem identification and referral services during the past 6 months (reported in Question 103a/b), estimate how many have any of the following disabilities. In this case, the total number of respondents with the disabilities below may be higher or lower than the total of participants reported in Question 103a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

109a. Deaf or difficulty hearing: _____________

109b. Blind or difficulty seeing (even with glasses): _____________

109c. Serious difficulty walking or climbing stairs: ___________

109d. Difficulty dressing or bathing: _____________

109e. Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition: _____________

109f. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition: _____________

109g. Disability status unknown: ___________

110. Of the total number of (new) participants served by your problem identification and referral services during the past 6 months (reported in Question 103a/b), estimate how many currently serve in the military. The number of current Armed Forces, Reserves, and National Guard service members, along with the former members, nonmembers, and unknown, should add up to the total of participants reported in Question 103a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

110a. Currently serve in the Armed Forces: _____________

110b. Currently serve in the Reserves: _____________

110c. Currently serve in the National Guard: _____________

110d. Served in the past, but do not currently serve in the Armed Forces, Reserves, or National Guard: _________

110e. Never served in the Armed Forces, Reserves, or National Guard: _________

110f. Military status unknown: ___________

111. Of the total number of (new) participants served by your problem identification and referral services during the past 6 months (reported in Question 103a/b), estimate how many are family members of active duty or separated/retired Armed Forces, Reserves, and National Guard service members. The number of family members of active duty and separated/retired Armed Forces, Reserves, and National Guard service members, along with the nonfamily members and unknown, should add up to the total of participants reported in Question 103a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

111a. Family member of someone on active duty in the Armed Forces, Reserves, or National Guard: ______

111b. Family member of someone separated or retired from the Armed Forces, Reserves, or National Guard: ______

111c. Not a family member of someone on active duty in, separated from, or retired from the Armed Forces, Reserves, or National Guard: _____________

111d. Military family member status unknown: ___________

Environmental Strategies Sub-Form

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

Throughout this section, you refers to your organization, or partners with your organization. For example, if you worked with the police department to conduct more sobriety checkpoints, you would report this activity on this form.

112. When did you first start conducting the environmental strategy for your PFS initiative? (Provide MM/YYYY.)^{E (autofill after first completed)}

___________ MM /YYYY

In the remainder of this sub-form, you will be asked to report the following environmental strategy types as relevant to your PFS activities (if applicable, you will be able to describe other types of environmental activities at the end of this sub-form):

• Training of environmental influencers (e.g., responsible beverage server training, law enforcement training)—people who are in positions to affect substance abuse through policy, enforcement, communication, and so on (e.g., law enforcement officers, beverage servers, merchants, health care professionals, school employees);

• Policy enactment, establishment, or implementation (e.g., policies related to retail access, public consumption, or advertising; organizational policies; interactions with elected officials); and

• Enforcement (e.g., sobriety checkpoints, compliance checks, neighborhood surveillance).

Training of environmental influencers

In this section, report strategies that include training for those in positions to affect substance abuse through policy, enforcement, communication, and so on (e.g., law enforcement officers, beverage servers, merchants, health care professionals, school employees). Include only training related to the specific environmental strategy on which you are reporting in this sub-form. Do not include training conducted for other environmental strategies that you have listed as separate environmental strategies.

113. Did this environmental strategy include training of environmental Influencers—that is, those in positions to affect substance abuse through policy, enforcement, communication, and so on (e.g., law enforcement officers, beverage servers, health care professionals, school employees)? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 121.)

114. Is this a recurring prevention intervention, in which the same group of people is trained over multiple sessions? An example would be a set of training sessions delivered to the same group of participants every Monday night for 6 weeks. (Select one response.)^{E (autofill after first completed)}

• Yes

• No

115a. Is this training of environmental influencers implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a holding a new set of training sessions each month? If your training sessions take place for a period of time with the same participants and then start over with new participants, select “yes.” A training of environmental influencers can be both recurring and implemented in a series of cycles. (Select one response.)^{E (autofill after first completed)}

• Yes

• No (If selected, you will automatically proceed to Question 116.)

115b. How many groups of participants started the training of environmental influencers during the past 6 months? Do not include groups counted in previous reporting periods. This response should be written as a whole number (e.g., 4).^E

__________________________ groups started

115c. How many groups of participants completed the training of environmental influencers during the past 6 months? Include groups that started and completed in this reporting period as well as groups that started in prior reporting periods but completed in this one. This response should be written as a whole number (e.g., 4).^E

_________________________ groups completed

116. To which group(s) did you provide training to affect substance abuse through policy, enforcement, communication, and so on during the past 6 months? (Select all that apply.)^{E (autofill after first completed)}

• Law enforcement

• Beverage servers

• Alcohol merchants

• Health care professionals

• School employees or administrators

• Business owners or employees

• Service or civic organization employees or administrators

• Media members

• Military personnel

• Other (Describe) ______________________________________________________

117. What was/were the format(s) of the training of environmental influencers during the past 6 months? (Select all that apply.)^{E (autofill after first completed)}

• Individual

• Small group (2–9)

• Large group (10–49)

• Extra-large group (50+)

• Web-based

• Other (Describe.) ________________________________________________________

118. How many training sessions were conducted for each group of environmental influencers during the past 6 months? This response should be written as a whole number (e.g., 4).^E

___________ sessions

119. What was the average length of the individual training sessions, in hours, during the past 6 months? This response should be written as a whole number (e.g., 4).^E

____________ hours

120a. How many individuals participated in the training of environmental influencers during the past 6 months? This response should be written as a whole number (e.g., 4).^E

_____________ individuals

120b. Of those who participated in the training of environmental influencers, how many were new to the training sessions during the past 6 months? New participants are participants who had not participated in the sessions before and were therefore not previously counted in any prior reporting period. If you are unsure of the exact number of new participants, respond with your best estimate. Note that the number reported in 120b will always be smaller than or equal to the number reported in 120a.^E

__________________________________ new participants

Policy enactment, establishment, or implementation

121. Did this environmental strategy include policy enactment, establishment, or implementation? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 127.)

122a. For this particular environmental strategy, how many different organizations did you engage during the past 6 months to result in the policy change, establishment, or implementation? For example, if you targeted changing school policies, count the school district or individual schools engaged in that change. If you targeted changing policies related to retail access, count the relevant government entity or alcohol establishments engaged in that change.^E

different organizations

122b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those organizations engaged during the past 6 months, how many were new during this second half of the Federal fiscal year? New organizations are those that had not been engaged previously and therefore not counted in the first 6 months of the year. Note that the number reported in Question 122b will always be smaller than or equal to the number reported in Question 122a.^E

__________ new organizations (If none, enter “0”)

Indicate which of the following activities you worked to implement during this reporting period related to policy. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate interventions.

123. Mark the activity or activities that best reflect what you did during the past 6 months for this particular environmental strategy. (Select all that apply.)^E

• Worked to enact policies related to retail access (e.g., liquor outlet regulations on location, density, hours and zoning; keg registration; prescription drug monitoring programs)

• Worked to enact policies related to social access (e.g., parental hosting laws, prescription drug take back policies)

• Worked to enact policies related to consumption of substances in public places (e.g., open container laws)

• Worked to enact regulations on alcohol or prescription drug advertising and billboard placements in the community

• Worked to establish school, workplace, or organizational policies related to substance use (e.g., drug/alcohol-free school zones, workplace use policies, recreation league policies)

• Worked to enact policies to reduce the problems/consequences associated with substance abuse (e.g., crime, driving under the influence)

• Other (Describe.) ______________________________

124a. For this particular environmental strategy, did you contact your elected officials to provide information about policies to be enacted (e.g., to prohibit new alcohol outlets in the community; to establish a prescription drug monitoring program) during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 126.)

124b. How many elected officials were contacted during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ elected officials

125. For this particular environmental strategy, did you conduct other policy-related interventions or conduct other activities to effect policy change during the past 6 months?^E

• Yes (Describe; 3,000-character limit.)
  
  
  

• No

126. Describe any new policies that were enacted, established, or implemented during the past 6 months related to this particular environmental strategy. ^E

(Describe; 3,000-character limit.)

Enforcement

127. Did this environmental strategy include enforcement efforts (e.g., compliance checks, sobriety checkpoints, neighborhood surveillance, prescription drug monitoring)? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 132.)

Indicate which of the following activities you worked to implement during this reporting period related to enforcement. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate environmental strategies.

128a. For this particular environmental strategy, did you conduct compliance checks that target merchants who sell alcohol to minors during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 129.)

128b. How many compliance checks were conducted during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ compliance checks

129a. For this particular environmental strategy, did you establish sobriety checkpoints during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 130.)

129b. How many separate sobriety checkpoints were established during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ sobriety checkpoints

130a. For this particular environmental strategy, did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community for sting operations, conduct sobriety check-points) during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 131.)

130b. How many different law enforcement agencies were engaged in collaboration during the past 6 months? This response should be written as a whole number (e.g., 4).^E

__________ law enforcement agencies engaged

131. For this particular environmental strategy, did you work to implement other enforcement practices or conduct other activities to affect the implementation of enforcement activities during the past 6 months? (Select one response.)^E

• Yes (Describe; 3,000-character limit)
  
  
  

• No

Other environmental interventions

132. If this environmental strategy did not fall into the categories of policy, enforcement, or training of environmental influencers, describe the environmental strategy you worked to or did implement during this reporting period.^E

• Yes (Provide a concise written description in the space available; 3,000-character limit.)
  
  
  

• No

The questions in this section collect information on the individuals reached through your training of environmental influencers, enforcement efforts, policy-related activities, or other environmental strategies. This set of questions specifically refers to [NAME OF PREVENTION TYPE].

133a. Estimate the total number of individuals who were reached or affected by your environmental strategy during the past 6 months. If you are unsure of the exact number of individuals affected respond with your best estimate. ^E

__________ total individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

133b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those who received or were reached or affected by your environmental strategy during the past 6 months, how many were new during this second half of the Federal fiscal year? If you are unsure of the exact number of new individuals reached, respond with your best estimate. New individuals are those who had not been reached or affected by your environmental strategies before and were therefore not previously counted in the first 6 months of the year. Note that the number reported in Question 133b will always be smaller than or equal to the number reported in Question 133a. For example, if you reported an enforcement-related activity reaching one town (3,000 people) during the first half of the year, and this strategy continued within that same town in the second half, the total number reported at the end of both halves would be 3,000, but the “new” number would be 3,000 for the first half and 0 for the second half.^E

__________ new individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

134. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of participants reported in Question 133a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

134a. Number of females: _____________

134b. Number of males: ______________

134c. Number gender unknown: _______________

135. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in Question 133a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

135a. Children age 0 to 11: _____________

135b. Youth age 12 to 17: _____________

135c. Young adults age 18 to 20: _____________

135d. Young adults age 21 to 25: ______________

135e. Adults age 26 and older: _____________

135f. Age unknown: ______________

136. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, White, multiracial, other, and unknown should add up to the total of participants reported in Question 133a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

136a. American Indian or Alaska Native: _____________

136b. Black or African American: _____________

136c. White: _____________

136d. Asian: _____________

136di. Asian Indian: _______________

136dii. Chinese: __________________

136diii. Filipino: __________________

136div. Japanese: ________________

136dv. Korean: ___________________

136dvi. Vietnamese: _______________

136dvii. Other Asian: _______________

136e. Native Hawaiian or Other Pacific Islander: ______________

136ei. Native Hawaiian: _______________

136eii. Guamanian or Chamorro: _______________

136eiii. Samoan: __________________

136eiv. Other Pacific Islander: __________________

136f. Multiracial: ___________

136g. Other: _____________

136h. Race unknown: ___________

137. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 133a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

137a. Hispanic, Latino/a, or of Spanish origin: ____________

137ai. Mexican, Mexican American, Chicano/a: _____________

137aii. Puerto Rican: ______________________

137aiii. Cuban: ________________________

137iv. Other Hispanic, Latino, or Spanish origin: ________________

137b. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

137c. Hispanic ethnicity unknown: ____________

138a. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), estimate how many speak English at each of the levels indicated below. The number speaking English very well, well, not well, not at all, and unknown should add up to the total number of participants reported in Question 133a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

138ai. Very Well: _____________

138aii. Well: _____________

138aiii. Not Well: _____________

138aiv. Not at all: ___________

138av. English language ability unknown: _________________

138b. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), estimate how many speak any of the languages below as the primary language at home. The number of English speakers, Spanish speakers, other language speakers, and unknown should add up to the total of participants reported in Question 133a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

138bi. English: _____________

138bii. Spanish: _____________

8139biii. Other language: _____________

8139biv. Language unknown: ___________

139. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), estimate how many have any of the following disabilities. In this case, the total number of respondents with the disabilities below may be higher or lower than the total of participants reported in Question 133a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

139a. Deaf or difficulty hearing: _____________

139b. Blind or difficulty seeing (even with glasses): _____________

139c. Serious difficulty walking or climbing stairs: ___________

139d. Difficulty dressing or bathing: _____________

139e. Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition: _____________

139f. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition: _____________

139g. Disability status unknown: ___________

140. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), estimate how many currently serve in the military. The number of current Armed Forces, Reserves, and National Guard service members, along with the former members, nonmembers, and unknown, should add up to the total of participants reported in Question 133a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

140a. Currently serve in the Armed Forces: _____________

140b. Currently serve in the Reserves: _____________

140c. Currently serve in the National Guard: _____________

140d. Served in the past, but do not currently serve in the Armed Forces, Reserves, or National Guard: _________

140e. Never served in the Armed Forces, Reserves, or National Guard: _________

140f. Military status unknown: ___________

141. Of the total number of (new) participants reached by your environmental strategy during the past 6 months (reported in Question 133a/b), estimate how many are family members of active duty or separated/retired Armed Forces, Reserves, and National Guard service members. The number of family members of active duty and separated/retired Armed Forces, Reserves, and National Guard service members, along with the nonfamily members and unknown, should add up to the total of participants reported in Question 133a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

141a. Family member of someone on active duty in the Armed Forces, Reserves, or National Guard: ______

141b. Family member of someone separated or retired from the Armed Forces, Reserves, or National Guard: ______

141c. Not a family member of someone on active duty in, separated from, or retired from the Armed Forces, Reserves, or National Guard: _____________

141d. Military family member status unknown: ___________

Information Dissemination Sub-Form

Name of Prevention Intervention: _________________________________^{E (autofill from Question 33)}

Service Type: ___________________________________________ ^{E (autofill from Question 33)}

142. When did you first start conducting this information dissemination (and other communication activities) service type as part of your PFS initiative? (Provide MM/YYYY.)^{E (autofill after first completed)}

_________ MM/YYYY

143. What was/were the intended purpose(s) of the communication or information that you disseminated for this service type? (Select all that apply.)^E

• To raise awareness of one or more specific substance use prevention problems in the community

• To gain support from the community for substance abuse prevention efforts

• To provide information on community norms related to substance use

• To provide information on the risks of substance use

• To provide substance abuse prevention information (e.g., information on securing prescription drugs in the household, information on resisting alcohol offers)

• To change individual behaviors with regard to substance use

• 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 suspect underage alcohol sales at a particular establishment)

• To provide a directory of substance use prevention resources in the community

• Other (Describe.) ________________________________________

144. Did this service type include communication efforts to raise community awareness of underage alcohol use or prescription drug misuse problems during the past 6 months? Awareness-raising activities are those in which your primary purpose is to draw attention to a substance abuse problem or to your prevention efforts. These activities are not intended to recruit participants or volunteers, although that may happen. (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 147.)

145. Indicate the community members and groups (i.e., target audience) to whom you are presenting awareness-raising information. (Select all that apply.)^E

• The general public

• Youth groups or representatives

• Schools or school districts

• Youth-serving organizations other than schools (e.g., Big Brothers/Big Sisters, Boy Scouts/Girl Scouts)

• Parents, family, or caregiver groups

• Advocacy volunteers

• Business community

• Media (e.g., radio and television stations, newspapers and magazines)

• Faith-based organizations (e.g., churches, charitable organizations with religious affiliations such as Catholic Charities)

• Civic or volunteer organizations (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)

• LGBTQ-supportive organization

• Military or veteran organization

• Law enforcement agencies (e.g., local, tribal, State, and Federal law enforcement agencies, including the police, the Federal Bureau of Investigation [FBI], the Drug Enforcement Administration [DEA], and the Bureau of Alcohol, Tobacco, Firearms and Explosives [ATF])

• Local or State, tribal, or jurisdiction courts

• State departments of justice (e.g., judicial department, department of juvenile justice, department of criminal justice, attorney general’s office)

• U.S. Department of Justice (excluding their law enforcement arms mentioned above [i.e., FBI, DEA, ATF])

• State, tribal, or local jails and prisons

• Health care professionals

• State, tribal, jurisdiction, or local public health departments

• Mental health professionals or agencies

• Other State, tribal, or jurisdiction government agencies (e.g., public health, public safety, social services, American Indian tribal government)

• Local, village, or tribal agencies (mayor’s office, city council, tribal council, Alaska Native Corporation agencies)

• Other (Describe.)

146. Indicate the total number of different community groups or organizations to whom you presented awareness-raising information during the past 6 months, if any. This response should be written as a whole number (e.g., 4).^E

community groups or organizations (If none, enter “0.”)

147. For this particular service type, did you engage in a social marketing or social norms campaign during the past 6 months? Social marketing is using the principles of commercial marketing to develop, implement, and evaluate programs designed to influence the behavior of a target audience. Rather than dictating the way that information is to be conveyed, social marketing involves listening to the needs and desires of the target audience and building the program from there. Social norms campaigns use a variety of methods to correct negative misperceptions (usually overestimations of use) and to identify, model, and promote the healthy, protective behaviors that are the actual norm in a given population. (Select one response.)^E

• Yes

• No

148. Indicate the type(s) of individuals targeted by this or information dissemination (and other communication activities) service type during the past Federal fiscal year.^{A (autofill after first completed)}

148a. Age group(s) targeted by information dissemination (and other communication activities) service type during the past Federal fiscal year: (Select all that apply.)

• Children age 0 to 11

• Youth age 12 to 17

• Young adults age 18 to 20

• Young adults age 21 to 25

• Adults age 26 or older

• Other (Describe.)

148b. Population type(s) targeted by the information dissemination (and other communication activities) service type during the past Federal fiscal year: (Select all that apply.)

• Middle school students

• High school students

• College students

• Parents

• Health care providers

• Employees

• Current or former military members

• Military family members

• Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

• Individuals living in poverty

• Individuals whose native language is other than English

• Individuals with low literacy

• Individuals with mental illness

• Individuals with disabilities (e.g., hearing, visually, or physically impaired)

• Other (Describe.)

149a. For this particular information dissemination (and other communication activities) service type, did you create or air television ads during the past 6 months? (Select one response)^E

• Yes

• No (If selected, you will automatically proceed to Question 150.)

149b. How many individual times did the television ads air during the past 6 months? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).^E

times

149c. How many weeks did the television ads air during the past 6 months? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).^E

weeks

149d. How many different televisions stations aired the ads air during the past 6 months? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).^E

stations

149e. Provide any information you have on the reach of the television ads aired during the past 6 months. This could include information provided by the television stations or advertising agency on ratings points; the average number of viewers at the time the ads aired; the geographic area where the ads aired; and the target audience of the related television programs.^E

(Describe; 3,000-character limit.)

150a. For this particular information dissemination (and other communication activities) service type, did you create or air radio ads during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 151.)

150b. How many individual times did the radio ads air during the past 6 months? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).^E

times

150c. How many weeks did the radio ads air during the past 6 months? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).^E

weeks

150d. How many different radio stations aired the ads air during the past 6 months? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4). ^E

stations

150e. Provide any information you have on the reach of the radio ads aired during the past 6 months. This could include information provided by the radio stations or advertising agency on ratings points; the average number of listeners at the time the ads aired; the geographic area where the ads aired; and the target audience of the related radio broadcast.^E

(Describe; 3,000-character limit.)

151a. For this particular communication strategy, did you create or publish print ads during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 152.)

151b. How many individual times did the print ads run during the past 6 months? (Select one response.)^E

times

151c. How many different newspapers or magazines displayed the ads during the past 6 months? Insert “0” if ads were created but not distributed during the period. This response should be written as a whole number (e.g., 4).^E

newspapers or magazines

151d. Provide any information you have on the reach of the print ads run during the past 6 months. This could include information provided by the newspaper or magazine on its average readership; the geographic area in which the publication was distributed; and the target audience of the publication.^E

(Describe; 3,000-character limit.)

152. For this particular information dissemination (and other communication activities), how many special events (e.g., alcohol-free concerts; invited speakers) were hosted during the past 6 months? This response should be written as a whole number (e.g., 4).^E

special events

153. For this particular information dissemination (and other communication activities) service type, how many other promotional activities (e.g., providing alcohol-free pamphlets at a health fair, distributing prescription drug take-back information at a school) were hosted during the past 6 months? This response should be written as a whole number (e.g., 4).^E

promotional activities

154a. For this particular information dissemination (and other communication activities) service type, did you present at community meetings (e.g., parent-teacher association [PTA] meetings, town hall meetings, school assemblies) during the past 6 months? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 155.)

154b. How many community meetings did you present at during the past 6 months? This response should be written as a whole number (e.g., 4).^E

meetings

154c. What was the total number of participants at all community meetings where you presented during the past 6 months? This response should be written as a whole number (e.g., 4).^E

participants

155a. For this particular information dissemination (and other communication activities) service type, did you send letters to the editor of the local newspaper or community newsletters during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 156.)

155b. How many letters were published during the past 6 months? This response should be written as a whole number (e.g., 4).^E

letters

156a. For this particular information dissemination (and other communication activities) service type, did you develop or broadcast substance abuse prevention PSAs during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 157.)

156b. How many times were the PSAs broadcast during the past 6 months? This response should be written as a whole number (e.g., 4).^E

times

157a. For this particular information dissemination (and other communication activities) service type, did you produce or distribute substance abuse prevention posters during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 158.)

157b. How many posters were distributed during the past 6 months? This response should be written as a whole number (e.g., 4).^E

posters

158a. For this particular information dissemination (and other communication activities) service type, did you produce or distribute substance abuse prevention brochures during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 159.)

158b. How many brochures were distributed during the past 6 months? This response should be written as a whole number (e.g., 50).^E

brochures

159a. For this particular information dissemination (and other communication activities) service type, did you provide a related information line or hotline in the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 160.)

159b. How many individuals called into the information line or hotline in the past 6 months? This response should be written as a whole number (e.g., 50).^E

individuals

160. For this particular information dissemination (and other communication activities) service type, did you develop or run a prevention-focused clearinghouse or information resource center in the past 6 months? (Select one response.)^E

• Yes

• No

161a. For this particular information dissemination (and other communication activities) service type, did you launch or continue prevention-focused Web sites or Facebook pages during the past 6 months? (Select one response.)^E

• Yes

• No (If selected, you will automatically proceed to Question 162.)

161b. What is the number of visitor sessions (visits) that the Web sites had during the past 6 months? This response should be written as a whole number (e.g., 4).^E

• Specify number of visits _____

• Do not know

161c. How many new (compared with returning) visitors did the Web sites have during the past 6 months? This response should be written as a whole number (e.g., 4).^E

• Specify number of new visitors _____

• Do not know

161d. What is the total number of unique page views that the Web sites had during the past 6 months? This response should be written as a whole number (e.g., 4).^E

• Specify number of unique page views _______

• Do not know

161e. What was the average amount of time spent on the Web sites during the past 6 months? This response should be written in the hours:minutes:seconds format (e.g., 00:14:30 means that the average amount of time spent on the Web site was 14 minutes and 30 seconds).^E

• Specify time spent (hours:minutes:seconds) ___ : ___ : ___

• Do not know

162. For this particular information dissemination (and other communication activities) service type, did you conduct other communication activities during the past 6 months?^E

• Yes (Describe; 3,000-character limit.)
  
  
  

• No

The questions in this section collect information on the individuals reached through your information dissemination (and other communication activities) service type activities.

163a. Estimate the total number of individuals who were reached or affected by your information dissemination (and other communication activities) service type activities for during the past 6 months. If you are unsure of the exact number of individuals affected, respond with your best estimate. ^E

__________total individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

163b. (THIS ITEM WILL NOT APPEAR FOR THE FIRST HALF OF THE YEAR) Of those who received or were affected by your information dissemination (and other communication activities) service type activities during the past 6 months, how many were new during this second half of the Federal fiscal year? If you are unsure of the exact number of new individuals reached, respond with your best estimate. New individuals are those who had not been reached or affected by your communication activities before and were therefore not previously counted in the first 6 months of the year. Note that the number reported in Question 163b will always be smaller than or equal to the number reported in Question 163a. For example, if you reported a communication-related activity reaching one town (3,000 people) during the first half of the year, and this strategy continued within that same town in the second half, the total number reported at the end of both halves would be 3,000, but the “new” number would be 3,000 for the first half and 0 for the second half.^E

__________ new individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

164. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), indicate how many were male and how many were female. The number of females, males, and unknown should add up to the total of participants reported in Question 163a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

164a. Number of females: _____________

164b. Number of males: ______________

164c. Number gender unknown: _______________

165. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), indicate how many were in each of the age groups listed below. The number children, youth, young adults, adults, and unknown should add up to the total of new participants reported in Question 163a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

165a. Children age 0 to 11: _____________

165b. Youth age 12 to 17: _____________

165c. Young adults age 18 to 20: _____________

165d. Young adults age 21 to 25: ______________

165e. Adults age 26 and older: _____________

165f. Age unknown: ______________

166. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, White, multiracial, other, and unknown should add up to the total of participants reported in Question 163a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

166a. American Indian or Alaska Native: _____________

166b. Black or African American: _____________

166c. White: _____________

166d. Asian: _____________

166di. Asian Indian: _______________

166dii. Chinese: __________________

166diii. Filipino: __________________

166div. Japanese: ________________

166dv. Korean: ___________________

166dvi. Vietnamese: _______________

166dvii. Other Asian: _______________

166e. Native Hawaiian or Other Pacific Islander: ______________

166ei. Native Hawaiian: _______________

166eii. Guamanian or Chamorro: _______________

166eiii. Samoan: __________________

166eiv. Other Pacific Islander: __________________

166f. Multiracial: ___________

166g. Other: _____________

166h. Race unknown: ___________

167. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 163a/b. This response should be written as a whole number (e.g., 4) and not as a percentage.^E

167a. Hispanic, Latino/a, or of Spanish origin: ____________

167ai. Mexican, Mexican American, Chicano/a: _____________

167aii. Puerto Rican: ______________________

167aiii. Cuban: ________________________

167iv. Other Hispanic, Latino, or Spanish origin: ________________

167b. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

167c. Hispanic ethnicity unknown: ____________

168a. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), estimate how many speak English at each of the levels indicated below. The number speaking English very well, well, not well, not at all, and unknown should add up to the total number of participants reported in Question 163a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

168ai. Very well: _____________

168aii. Well: _____________

168aiii. Not well: _____________

168aiv. Not at all: ___________

168av. English language ability unknown: _________________

168b. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), estimate how many speak any of the languages below as the primary language at home. The number of English speakers, Spanish speakers, other language speakers, and unknown should add up to the total of participants reported in Question 163a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

168bi. English: _____________

168bii. Spanish: _____________

168biii. Other language: _____________

168biv. Language unknown: ___________

169. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), estimate how many have any of the following disabilities. In this case, the total number of respondents with the disabilities below may be higher or lower than the total of participants reported in Question 163a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

169a. Deaf or difficulty hearing: _____________

169b. Blind or difficulty seeing (even with glasses): _____________

169c. Serious difficulty walking or climbing stairs: ___________

169d. Difficulty dressing or bathing: _____________

169e. Difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition: _____________

169f. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition: _____________

169g. Disability status unknown: ___________

170. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), estimate how many currently serve in the military. The number of current Armed Forces, Reserves, and National Guard service members, along with the former members, nonmembers, and unknown, should add up to the total of participants reported in Question 163a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

170a. Currently serve in the Armed Forces: _____________

170b. Currently serve in the Reserves: _____________

170c. Currently serve in the National Guard: _____________

170d. Served in the past, but do not currently serve in the Armed Forces, Reserves, or National Guard: _________

170e. Never served in the Armed Forces, Reserves, or National Guard: _________

170f. Military status unknown: ___________

171. Of the total number of (new) participants reached by your information dissemination (and other communication activities) service type activities during the past 6 months (reported in Question 163a/b), estimate how many are family members of active duty or separated/retired Armed Forces, Reserves, and National Guard service members. The number of family members of active duty and separated/retired Armed Forces, Reserves, and National Guard service members, along with the nonfamily members and unknown, should add up to the total of participants reported in Question 163a/b. Each response should be written as a whole number (e.g., 4) and not as a percentage. ^E

171a. Family member of someone on active duty in the Armed Forces, Reserves, or National Guard: ______

171b. Family member of someone separated or retired from the Armed Forces, Reserves, or National Guard: ______

171c. Not a family member of someone on active duty in, separated from, or retired from the Armed Forces, Reserves, or National Guard: _____________

171d. Military family member status unknown: ___________

Prevention Intervention Costs

For Questions 172 through 180, provide information on the costs of implementing [NAME OF PREVENTION INTERVENTION] during the past Federal fiscal year (from October XXXX to September XXXX); that is, your organization’s ongoing operating costs for this prevention intervention. First, we ask you to report your total costs across all resource categories (Question 172), and then we ask you to report costs for specific resource categories (e.g., personnel, supplies, building space, etc.; Questions 173 through 180). Financial staff should help complete questions on these questions as needed. You can also use the SAMHSA prevention program cost template (found at PUT LINK HERE) to help you calculate your costs for each of the questions in this section. Report all intervention implementation-related costs, regardless of the source paying for them. If you are implementing multiple intervention strategies, provide information here for this prevention intervention strategy only. Do not include in-kind contributions (e.g., volunteer labor or donated supplies), as these resources will be captured in the next section. Also do not include start-up costs or costs related to initial intervention development (i.e., costs related to purchasing or development of the intervention, hiring or training initial staff, or recruiting partners to assist with implementation). You will be able to provide that information in a later section.

172. Total Costs—What were the total costs (labor and nonlabor) that your organization incurred during the past Federal fiscal year (from October XXXX to September XXXX ) to implement the prevention intervention (i.e., the ongoing operating costs)? Do not include the value of in-kind resources (e.g., volunteer labor or donated supplies) as these will be captured in the next section. ^A

$_______________ total costs of implementing [NAME OF PREVENTION INTERVENTION] during the past Federal fiscal year

173a. Personnel Costs—What was the total labor expense (including all fringe benefits and payroll taxes) for paid employees who contributed to implementing the prevention intervention during the past Federal fiscal year (from October XXXX to September XXXX)? Do not include the costs for contracted services, as these will be captured in Question 172 below.^A

$_______________ total costs of paid employees during the past Federal fiscal year

173b. For each job category listed below, provide the number of full-time equivalents (FTEs, based on a 40-hour workweek) for staff in that category who contributed to implementing the prevention intervention during the past Federal fiscal year (from October XXXX to September XXXX). For the FTEs, you may enter numbers up to two decimal places.^A

Helpful Hint: The question above refers to staff in terms of FTEs. FTE is the fraction of time that a staff member works relative to a full-time worker (i.e., 40 hours per week). For example, a full-time staff member is equal to 1.0 FTE. Use decimals to indicate partial FTEs. For example, one half-time staff member is equal to 0.5 FTE and a quarter-time staff member is equal to 0.25 FTE.

Job type categories	FTEs contributed to implementing intervention
Intervention implementation staff
Other staff (e.g., administrative, supervisory, evaluation, and support staff)
TOTAL FTEs	0.00

174. What was the total cost of contracted services during the past Federal fiscal year (from October XXXX to September XXXX)? These costs refer to contracts with a person or with a company/corporation to provide a service related to implementation of your intervention. Examples of contracted services include radio advertisements and contracts to support compliance checks. Remember to report all intervention implementation-related contract costs, regardless of the source paying for them, but do not include start-up costs or costs related to initial intervention development. All contracted employees should be included in the total personnel costs above and not in the contracted costs here.^A

$__________ total cost of contracted services during the past Federal fiscal year

175a. Provide the total costs during the past Federal fiscal year (from October XXXX to September XXXX) for any intervention supplies, incentives, and office supplies related to your intervention implementation. Examples of supplies include pamphlets and program workbooks. Remember to report all intervention implementation-related costs, regardless of the source paying for them, but do not include start-up costs or costs related to initial intervention development. ^A

Program supplies, incentives, and office supplies	Total costs
Intervention supplies	$0.00
Incentives (excluding paying for transportation costs)	$0.00
General office supplies and minor equipment (excluding equipment over $2,000)	$0.00
TOTAL: Supplies, incentives, and offices supplies expenses	$0.00

175b. If the costs for incentives are greater than $0, describe the purpose of the incentives and provide more detailed information on how those incentives were given to participants (e.g., $20 gift cards provided to each participant at the end of the intervention). Provide a concise written description in the space available (3,000-character limit). ^A

176. Ongoing Training Expenses—Provide the total non-labor costs for any ongoing regular training activities related to the intervention implementation during the past Federal fiscal year (from October XXXX to September XXXX). Cost for off-site training may include conference registration fees, airfare, lodging, per diem, and parking at or transport to the airport. Include only unique training costs (e.g., conference center costs) that have not been reported elsewhere. Exclude staff labor time, which should be captured in Question 173b above and exclude intervention supplies and office supplies costs, which should have been reported in Question 175 above. Do not include initial training costs that are incurred as part of start-up costs. You will be able to provide that information in a later section.^A

$__________ total non-labor cost of ongoing trainings during the past Federal fiscal year

^{177. Report the overhead rate for your organization in the appropriate field below, based on how the rate is applied (to labor and fringe only, to all direct costs, or to all direct costs with exceptions). For organizations operating in more than one location, report on the location where the majority of the spending for the program occurs.A (autofill after first completed)}

Organizational Overhead			Overhead rate (%)
If rate applies to labor and fringe ONLY, enter the rate here:
		Overhead amount =	$0
If rate applies to ALL direct costs WITHOUT exceptions, enter the rate here:
		Overhead amount =	$0
					Specify exceptions in the box below:
If rate applies to ALL direct costs WITH EXCEPTIONS*, enter the rate here and specify exceptions in the space provided to the right:
*If your organization has exceptions to your overhead rate, please note that your indirect rate will not be calculated automatically and included on the Summary Page. You will need to calculate more complex indirect rate structures such as these manually. If you wish to have this included on the Summary Page, enter the manually calculated overhead amount in the box below.
	Manually calculated overhead amount =
TOTAL: Organizational overhead (feeds to Summary Page)			$0

178. If your organization has a separate General & Administrative (G&A) rate, report it in the appropriate field below, based on how the rate is applied. Otherwise, leave this section blank. ^{A (autofill after first completed)}

General & Administrative (G&A)		G&A Rate (%)
If the rate applies to all direct costs and labor overhead, enter the rate here:
	G&A amount =	$0
				Specify exceptions in the box below:
If the rate applies to all direct costs and labor overhead WITH EXCEPTIONS*, enter the rate here and specify exceptions in the space provided to the right:
*If your organization has exceptions to your G&A rate, please note that your indirect rate will not be calculated automatically and included on the Summary Page. You will need to calculate more complex indirect rate structures such as these manually. If you wish to have this included on the Summary Page, enter the manually calculated G&A amount in the box below.
	Manually calculated G&A amount =
TOTAL: G&A (feeds to Summary Page)		$0

179a. Enter any additional space costs NOT covered by the rates above in the space below. Otherwise, leave this question blank.^A

$_________additional space costs during the past Federal fiscal year

179b. Specify the types of items (e.g., rent, utilities, liability insurance) that are covered by these additional costs.^A

Additional Space Costs—Description

^{180. Other/Miscellaneous Expenses—Identify any costs associated with your intervention implementation during the past Federal fiscal year (from October XXXX to September XXXX) that have not been reported previously and that are not covered by the overhead or G&A rates or both. Remember to report all intervention implementation-related costs, regardless of the source paying for them, but do not include start-up costs or costs related to initial intervention development. A}

Other/Miscellaneous
Description		Total cost
TOTAL: Other/miscellaneous (feeds to Summary Page)		$0.00

Prevention intervention in-kind contributions

For Questions 181 and 182, provide information on any in-kind resources (e.g., volunteer labor, donated supplies) that may have been used in implementing [NAME OF PREVENTION INTERVENTION] during the past Federal fiscal year (from October XXXX to September XXXX). If you are implementing multiple interventions, provide information here for this prevention intervention only. Do not include in-kind contributions to start-up activities. You will be able to provide that information in the next section.

^{181. Estimate the amount of in-kind labor that supported your intervention during the past Federal fiscal year (from October XXXX to September XXXX). In-kind labor may include time from volunteers (including time from coalition members not paid for by your organization) or donated time (not compensated) from paid staff above and beyond their salary expectations. For each job category shown, provide (1) the estimated time for all “volunteers,” regardless of the role they play (expressed as total FTEs based on a 40-hour workweek), and (2) the estimated value of that time. Think in terms of the salary your organization would need to pay someone to fulfill the same roles and responsibilities as the volunteers.A}

Job type	Estimated FTEs contributed to intervention Implementation	Estimated total value ($)
Intervention implementation staff
Other staff (e.g., administrative, supervisory, evaluation, and support staff)
TOTAL: In-kind labor contributions		$0.00

182. List any in-kind nonlabor contributions that supported your intervention implementation during the past Federal fiscal year (from October XXXX to September XXXX). Include office space only if it is donated to you. Do not include space in schools (e.g., classrooms, auditoriums).^A

In-kind contributions (nonlabor)	Total estimated value ($)
TOTAL: In-kind nonlabor contributions	$0.00

Start-up intervention costs

For Questions 183 through 188, provide information on start-up costs for [NAME OF PREVENTION INTERVENTION] and costs related to initial intervention development that were incurred during the past Federal fiscal year (from October XXXX to September XXXX) (i.e., costs related to purchasing or development of the intervention, hiring or training initial staff, or recruiting partners to assist with implementation). If you are implementing multiple interventions, provide information here for this prevention intervention strategy only. Report all start-up and development costs, regardless of the source paying for them.

183. Which of the following activity or activities did your organization undertake in the past Federal fiscal year (from October XXXX to September XXXX) related to starting up this prevention intervention? (Select all that apply.)^A

• Hired new staff to implement the intervention

• Purchased a prevention intervention

• Developed a new prevention intervention

• Participated in an initial training on the intervention

• Developed policies and procedure related to implementing the intervention

• Recruited partners to assist with intervention implementation

• Acquired additional building space to implement intervention activities

• Other start-up activities (Describe.)

• We did not conduct any start-up or intervention development activities in the past Federal fiscal year (If selected, you will automatically proceed to Question 187.)

184a. What was the total labor expense (including all fringe benefits and payroll taxes) for paid employees for their role in start-up or intervention development activities during the past Federal fiscal year (from October XXXX to September XXXX)? ^A

$_______________ total costs of paid employees for start-up or intervention development in the past Federal fiscal year

184b. For each job category listed below, provide the number of FTEs (based on a 40-hour workweek) for paid staff in that category for their role in start-up or intervention development activities the past Federal fiscal year (from October XXXX to September XXXX), under the appropriate category. ^A

Helpful Hint: The question above refers to staff in terms of FTEs. FTE is the fraction of time that a staff member works relative to a full-time worker (i.e., 40 hours per week). For example, a full-time staff member is equal to 1.0 FTE. Use decimals to indicate partial FTEs. For example, one half-time staff member is equal to 0.5 FTE and a quarter-time staff member is equal to 0.25 FTE.

Job type categories	FTEs contributed to start-up or intervention development activities
Intervention implementation staff
Other staff (e.g., administrative, supervisory, evaluation, and support staff)
TOTAL FTEs

^{185. Estimate the amount of in-kind labor that supported start-up or intervention development activities in the past Federal fiscal year (from October XXXX to September XXXX). In-kind labor may include time from volunteers (including time from coalition members not paid for by your organization) or donated time (not compensated) from paid staff above and beyond their salary expectations. For each job category shown, provide (1) the estimated start-up or intervention development time for all “volunteers,” regardless of the role they play (expressed as total FTEs based on a 40-hour workweek), and (2) the estimated value of that time. Think in terms of the salary your organization would need to pay someone to fulfill the same roles and responsibilities as the volunteers.} A

Job type	Estimated FTEs contributed to intervention	Estimated total value ($)
Intervention implementation staff
Other staff (e.g., administrative, supervisory, evaluation, and support staff)
TOTAL: In-kind labor contributions		$0.00

186. Initial Training Expenses—Provide information on any initial training non-labor costs related to the intervention implementation in the past Federal fiscal year (from October XXXX to September XXXX). Cost for each off-site trip may include conference registration fees, airfare, lodging, per diem, and parking at or transport to the airport. Include only unique training costs (e.g., conference center costs) that have not been reported elsewhere. Exclude staff labor time, which should be captured in Question 184b above. Do not include ongoing regular training costs that should have been reported in Question 176. ^A

$__________ total non-labor cost of initial trainings in the past Federal fiscal year

187. What other significant nonlabor costs did you incur for start-up or intervention development activities during the past Federal fiscal year (from October XXXX to September XXXX) for this intervention?^A

Nonlabor Start-up or Intervention Development Costs
Description	Total cost
TOTAL:	$0.00

188. List any other in-kind contributions that supported start-up or intervention development activities during the past Federal fiscal year (from October XXXX to September XXX). Do not report in-kind labor contributions below, as they should be reported in Question 185. ^A

In-kind contributions to start-up or intervention development	Total estimated value
TOTAL: In-kind contributions	$0.00

189. Provide any additional comments about your prevention intervention costs for [NAME OF PREVENTION INTERVENTION] here. (Provide a concise written description in the space available; 3,000-character limit.)^A

Adaptations

This section asks for information about any adaptations you made to [NAME OF PREVENTION INTERVENTION]. We understand that adapting a prevention intervention strategy can help make it more accessible to a specific population, and we would like your honest answers about adaptations you may have made. Adaptations may include changes in target population, implementer type, training, content, materials, cultural appropriateness, dosage, duration, or setting of the prevention intervention from that recommended by the prevention intervention developer. Adaptations can apply to formal prevention curricula, manuals, and materials, as well as to accepted and standard practice as described in the literature for environmental interventions. Consult with the intervention strategy implementers about any adaptations they may have made before answering these questions.

190. Is this a new intervention developed and tested by you, the subrecipient community? Some communities are funded to create new interventions for specific target populations, substances, and consequences that have been identified as problem areas in the community. If your intervention is one you developed and have tested or are planning on testing with a target population, select “yes.” (Select one response.)^{A (autofill after first completed)}

• Yes (If selected, you will automatically proceed to the next section.)

• No

191. Did you make any adaptations to the prevention intervention in the past Federal fiscal year?^A

• Yes

• No, we implemented the intervention exactly as specified. (If selected, you will automatically proceed to the next section.)

192. Did you make any adaptations to the content or format of intervention materials in the past Federal fiscal year? (Examples of adaptations include adding content to workbooks, adding handouts, revising pamphlets, or changing the format of a public service announcement [PSA] from a television advertisement to a billboard.) (Select one response.)^A

• Yes, to the content of the materials

• Yes, to the format of the materials

• Yes, to both the content and the format of the materials

• No

• Intervention developer or standard practice makes no recommendations for the content or format of intervention materials

193. Did you change the order of intervention activities in the past Federal fiscal year? (Examples of adaptations include changing the order of curriculum lessons or changing the standard order of core activities of an environmental intervention.) (Select one response.)^A

• Yes

• No

• Intervention developer or standard practice makes no recommendations for the order of intervention activities

194. Did you make any other adaptations to the curriculum or manual content of the prevention strategy in the past Federal fiscal year? (Examples of adaptations include not covering all planned topics in an intervention or not completing all core activities of an environmental intervention.) (Select one response.)^A

• Yes

• No

• No curriculum or manual content specifications provided

195a. Did you change the recommended dosage for this prevention intervention (e.g., the number of sessions, number of PSAs or other media spots) in the past Federal fiscal year? (Select one response.)^A

• Yes

• No

• Intervention developer or standard practice makes no recommendations for dosage (If selected, you will automatically proceed to Question 194.)

195b. Indicate the recommended dosage. (500-character limit.)^{A (autofill after first completed)}

___________________________________________

195c. Indicate the dosage you actually delivered. (500-character limit.)^A

___________________________________________

196a. Did you adapt the recommended duration (e.g., days or hours) of this prevention intervention in the past Federal fiscal year? (Examples of adaptations include changes in the number of days, weeks, or months over which program sessions are spread or changes in the recommended number of days or weeks that PSAs air.) (Select one response.)^A

• Yes

• No

• Intervention developer or standard practice makes no recommendations for duration (If selected, you will automatically proceed to Question 195.)

196b. Indicate the recommended duration of this prevention intervention. If applicable, include both the number of hours total and the number of days or weeks (500-character limit).^{A (autofill after first completed)}

___________________________________________

196c. Indicate the actual duration (e.g., days, hours, or weeks) spent delivering the prevention intervention in the past Federal fiscal year. If applicable, include both the number of hours total and the number of days or weeks (500-character limit).^A

___________________________________________

197. Did you make an adaptation to the setting of the prevention intervention (e.g., classroom, work site, billboard, television advertisement) in the past Federal fiscal year? (Select one response.)^A

• Yes

• No

• Intervention developer or standard practice makes no recommendations for setting

198. Was the intervention administered by the type of implementers intended by the prevention developer or standard practice (e.g., teacher, police officer) in the past Federal fiscal year? (Select one response.)^A

• Yes

• No

• Intervention developer or standard practice makes no recommendations regarding the type of implementers

199. Did the intervention implementers receive the suggested training before implementing the prevention intervention in the past Federal fiscal year? (Select one response.)^A

• Yes, all implementers received the suggested training

• Yes, but only some implementers received the suggested training

• No

• Intervention developer or standard practice makes no suggestions regarding the training

200. Did you adapt the prevention intervention to deliver it to a target population other than that indicated by the developer (or standard practice for environmental strategies) in the past Federal fiscal year? (Examples of adaptations include targeting an age group younger than the indicated target population; targeting pregnant teens as opposed to young adults age 18 to 24; or targeting at-risk teens rather than a more universal population of teens.) (Select one response.)^A

• Yes (Describe.) __________________

• No

• Intervention developer or standard practice makes no recommendations for target population

201. Were any adaptations made to address the cultural appropriateness of the prevention intervention strategy for a particular group (e.g., modifying the language or slang used, modifying the examples, including visuals of individuals who represent your target population) in the past Federal fiscal year? (Select one response.)^A

• Yes (Describe.) __________________

• No

Section 2E. Monitoring and Evaluation

This section collects information on your development of an evaluation plan. You are also asked to indicate whether a final evaluation report was developed and whether key findings from the evaluation were distributed to key stakeholders, key informants, or both.

202. Was the implementation of your prevention interventions monitored by the State-, tribal-, or jurisdiction-level agency in charge of the SPF-PFS funding during the past Federal fiscal year? (Select one response.)^A

• Not applicable—no prevention interventions were implemented during this reporting period

• Yes, all implemented prevention interventions were monitored

• Implementation of some prevention interventions was monitored, but not all interventions were monitored

• No

• Don’t know

^{203. Did you work on any of the following intervention evaluation activities related to process or outcomes evaluation of your PFS interventions during the past Federal fiscal year? Process evaluation focuses on how an intervention was implemented and operates. Outcomes evaluation looks at the impact of your interventions on your targeted consumption, consequence, or intervening variables. Outcomes evaluation may include pretest, exit, and follow-up data, as well as other types of data. (Select all that apply.)A}

Evaluation activity	Process evaluation	Outcome evaluation
203a. Develop or substantially revise an evaluation plan		
203b. Collect data		
203c. Analyze data		
203d. Produce an evaluation report		

204a. Have you made changes to the implementation of your prevention interventions during the past Federal fiscal year as the result of the analysis of your data? (Select one response.)^A

• Yes

• No (If selected, you will automatically proceed to Question 205.)

• Data not yet collected or analyzed (If selected, you will automatically proceed to the Contextual Factors section, Question 206.)

204b. Which prevention intervention(s) did you modify during the past Federal fiscal year as the result of the analysis of your data? (Select all that apply.)^A

• [INTERVENTION NAME HERE]

• [INTERVENTION NAME HERE]

• [INTERVENTION NAME HERE]

• [INTERVENTION NAME HERE]

• [INTERVENTION NAME HERE]

205. Did you communicate any evaluation findings to key stakeholders, key informants, or both in your community during the past Federal fiscal year? (Select one response.)^A

• Yes

• No

Section 3: Contextual Factors

Contextual factors are conditions that exist outside the scope of the prevention intervention activities but nevertheless influence the SPF process and prevention intervention delivery. Although you can incorporate knowledge of these factors into your planning and prevention interventions, they typically cannot be changed through intervention activities. Understanding the nature of contextual factors, however, is still helpful in evaluating the success of the prevention intervention.

^{206. We would like to learn about demographic, environmental, or cultural factors that may have introduced barriers and had an impact on PFS prevention activities in your community during this reporting period. How much impact did the following factors have on your prevention activities in the past Federal fiscal year? (Select one level of impact for each factor.)A}

Barrier	No impact	Low impact	Moderate impact	High impact
206a. Cultural norms, attitudes, or practices favoring substance use				
206b. Lack of community awareness of the extent or consequences of substance abuse				
206c. Community disorganization				
206d. High poverty rates/low socioeconomic status				
206e. High unemployment or underemployment				
206f. Low literacy, lack of education, education a low priority, or high dropout rates				
206g. Large recent refugee/immigrant population				
206h. Language barriers				
206i. Easy access to alcohol for underage youth				
206j. Easy access to prescription drugs for nonmedical use				
206k. Not enough funds for prevention interventions				
206l. Lack of relevant prevention interventions for specific populations at risk				
206m. Lack of transportation, difficulty reaching some parts of the community				
206n. Lack of trust in law enforcement, government, social services				
206o. Limited legal policies/laws or enforcement				
206p. Lack of drug-free activities for area youth				
206q. Lack of supervision for area youth				
206r. Events that included substance use and received local media coverage and influenced public opinion				
206s. Stressful events affecting large portions of the target population, such as large fires, hurricanes, earthquakes, or terrorist attacks				
206t. Other (Describe.) __________________ _________________________________				

Section 4: Closing Questions

207. Provide any additional comments about your SPF-PFS-related prevention intervention activities here. (Provide a concise written description in the space available; 3,000-character limit.)^E

208. Do you have any additional comments about any aspects of the SPF-PFS Initiative? (Provide a concise written description in the space available; 3,000-character limit.)^E

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Program Evaluation for Prevention Contract (PEP-C) 10/1/2014