Form Result Form Result Form Result Form

OMB No. 0930-0285

Expiration Date 5/21/2013

RESULT FORM

TRAC INFRASTRUCTURE, PREVENTION, & MH PROMOTION

GRANT ID (GRANT/CONTRACT/COOPERATIVE AGREEMENT NUMBER) |____|____|____|____|____|____|____|____|____|____|

INSTRUCTIONS: USE ONE FORM PER RESULT. A RESULT NAME MUST BE UNIQUE IN A GIVEN FFY QUARTER*. THE SAME RESULT NAME CAN ONLY BE USED IN FUTURE QUARTERS. IF APPLICABLE, ENTER THE NUMBER AND/OR PERCENT OR AMOUNT OF FUNDING. DATA MUST BE ENTERED ELECTRONICALLY IN THE TRAC SYSTEM (HTTPS://WWW.CMHS-GPRA.SAMHSA.GOV). ALL RESULTS THAT OCCUR WITHIN A GIVEN QUARTER MUST BE ENTERED WITHIN ONE CALENDAR MONTH OF THAT QUARTER’S END.

INDICATOR NUMBER AND NAME (EX. PD1. A POLICY CHANGE COMPLETED AS A RESULT OF THE GRANT): __________________________________________________________________

IS THIS A NEW RESULT NAME? YES NO

RESULT NAME: _________________________________________________________________

DATE RANGE OF COMPLETION*: __________________________________________________

RESULT DESCRIPTION:___________________________________________________________

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NUMBER (EXCLUDING PD1; WD4; F1, F2, AND F3; OC1; A4; NAB1 & AC1): ______________

NUMERATOR (A4, NAB1, & AC1 ONLY): ____________________________________________

DENOMINATOR (A4, NAB1, & AC1 ONLY): __________________________________________

AMOUNT OF FUNDING (F1&F3 ONLY): ______________________________________________

*ENTER ONE OF THE FOLLOWING FOR DATE RANGE OF COMPLETION: a) 10/01/XX - 12/31/XX (FFQ1); B) 01/01/XX - 03/31/XX (FFQ2); C) 04/01/XX - 06/30/XX (FFQ3); D) 07/01/XX - 09/30/XX (FFQ4)

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0285.  Public reporting burden for this collection of information is estimated to average 4 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.