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pdfSPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Form Approved
OMB No. ###
Expiration Date ###
Strategic Prevention Framework
for Prescription Drugs
(SPF-Rx)
Annual Implementation Instrument
February 2017
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Prevention
[TO BE UPDATED] Burden Statement: Public reporting burden of this collection of information is
estimated to average between xx minutes and xx 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 xxxxxxxx.
NOTE Timing of Instrument Items: E = Every time (annually).
B = Baseline only. F = Final only.
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Table of Contents
Information and Directions .......................................................................................................... 2
Purpose ........................................................................................................................... 2
Requirements .................................................................................................................. 2
Organization of the Survey .............................................................................................. 2
Inclusion of Key Informants ............................................................................................. 3
Helpful Materials .............................................................................................................. 3
Entering and Saving Data ................................................................................................ 3
Survey Assistance ........................................................................................................... 3
Definition of Terms ...................................................................................................................... 4
Section 1: Administrative Survey ................................................................................................. 6
Organization Type (Subrecipients only) ........................................................................... 6
PFS Funding History (Subrecipients only) ....................................................................... 7
Section 2: Strategic Prevention Framework ................................................................................ 8
Section 2A. Needs, Target Populations, and Resources Assessments............................ 8
Needs Assessment (Subrecipients only) .............................................................. 8
Data Sources (Subrecipients only) ....................................................................... 8
Targeted Populations and Outcomes (Both grantees and subrecipients
complete) ........................................................................................................... 11
Section 2B. Capacity Building and Sustainability (Subrecipients only) ........................... 14
Current Capacity (Subrecipients only) ................................................................ 14
Training and Technical Assistance (Subrecipients only)..................................... 15
Development of SPF-Rx Organizational Resources (Subrecipients only) ........... 16
Relationship Building (Subrecipients only) ......................................................... 18
Data Infrastructure (Subrecipients only) ............................................................. 21
Sustainability (Subrecipients only) ..................................................................... 22
Section 2C. Prevention Intervention Implementation (Both grantees and
subrecipients complete) ................................................................................................. 23
Implemented Prevention Interventions ............................................................... 24
Prevention Intervention and Service Type Information ....................................... 26
Community-Based Processes Sub-Form ........................................................... 30
Prevention Education Sub-Form ........................................................................ 34
Alternative Drug-Free Activities Sub-Form ......................................................... 37
Problem Identification and Referral Sub-Form ................................................... 41
Environmental Strategies Sub-Form .................................................................. 45
I.
Training and educating environmental influencers ......................... 45
II.
Policy, regulation, or law enactment or implementation.................. 47
III. Enforcement implementation ......................................................... 51
IV. Other environmental interventions ................................................. 52
Information Dissemination Sub-Form ................................................................. 56
Section 2D. Monitoring and Evaluation (Subrecipients only) .......................................... 64
Section 3: Implementation Barriers and Contextual Factors (Both grantees and
subrecipients complete) ............................................................................................................ 65
Section 4: Closing Questions (Both grantees and subrecipients complete) ............................... 68
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Strategic Prevention Framework for Prescription Drugs (SPF-Rx)
Cross-Site Evaluation, Annual Implementation Instrument
Information and Directions
Purpose
The Annual Implementation Instrument collects data annually from primary SPF-Rx grantees and
their subrecipient communities about SPF-Rx implementation, including:
■
Subrecipient communities’ progress through the Strategic Prevention Framework (SPF); and
■
The specific prevention interventions being implemented by subrecipient communities and
primary grantees. For SPF-Rx, interventions may be implemented by primary grantees as well
as their community subrecipients.
Subrecipient communities will complete the whole survey, while primary grantees will mainly report
on prevention interventions that they implement. Data collected from the survey will be used to
monitor subrecipient and state, tribal entity, or jurisdiction performance and evaluate the
effectiveness of the Strategic Prevention Framework for Prescription Drugs (SPF-Rx) program
across states, tribal entities, and jurisdictions. The overall goal of the cross-site evaluation is to
document and assess the effectiveness of the SPF-Rx approach to SAMHSA’s mission of
reducing 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 SPF-Rx grant initiative.
Organization of the Survey
Make sure to read all of the directions and examples, which are provided in italics. Primary
grantees and subrecipient communities will complete this form once for each Federal fiscal year
(annually). 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.
You will need to complete separate forms related to implementation information for each set of
prevention intervention activities implemented. For example, if your community/jurisdiction
implements both a participant-based education prevention intervention strategy and an
environmental prevention intervention strategy, you will complete implementation information for
both of those interventions. Similarly, if your community implements two different participant-based
prevention education intervention strategies, you 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 primary SPF-Rx grantee (state/tribal
entity/jurisdiction) or the subrecipient community that has received SPF-Rx funding from the
state/tribal entity/jurisdiction. The SPF-Rx subrecipient community could be an organization,
coalition, or other entity.
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Inclusion of Key Informants
You are strongly encouraged to obtain input from others involved with the SPF-Rx-funded project.
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-Rx grant.
People you may want to include in responding to this survey (if these positions are applicable to
your grant)—
■
Project Director
■
Project Coordinator
■
Person with responsibility or knowledge of financial issues
■
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 (xxx) xxx–xxxx or by email at (email address). You can request assistance
at any time and someone will respond to you within 24 hours or the next business day.
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
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-Rx, 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 prescription drug misuse prevention services, such as improving
organizational resources; improving awareness about prescription drug misuse problems;
building new relationships or strengthening existing relationships among coalitions, groups, and
organizations involved in prescription drug misuse 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 prescription drug and opioid misuse,
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 prescription drug misuse 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
misuse and abuse of prescription drugs—for example, overdoses and deaths related to
prescription drugs.
■
Consumption patterns are the ways in which people misuse prescription drugs.
■
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 prescription drug misuse.
Approaches can center on legal and regulatory issues or can relate to service and actionoriented initiatives. Examples include technical assistance (TA) to communities to increase
health care provider’s use of prescription drug monitoring program data when prescribing opioid
pain medication.
■
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 prescription drug
misuse 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.
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
■
In-kind resources include labor that supports the SPF-Rx grant at subsidized or no cost to the
grant or other resources donated to the SPF-Rx grant, such as equipment, supplies, or office
space.
■
Interventions are funded activities carried out under the auspices of the SPF-Rx grant. They
target a variety of subpopulations with the objective of improving outcomes related to
prescription drug and opioid misuse and abuse.
■
Key stakeholders are all the members of the community who have a vested interest (a stake) in
the activities or outcomes of a prescription drug misuse prevention intervention.
■
Leveraging resources is the process of combining SPF-Rx-funded resources with other
resources to augment prevention intervention delivery (i.e., to do more together than with SPFRx resources alone). For example, subrecipients combine SPF-Rx funding with funding from
another source (e.g., CDC Prevention for States) to augment the implementation of their SPF-Rx
intervention. In many instances, leveraging functions through collaborative relationships.
■
Participants are the recipients of the SPF-Rx prevention interventions.
■
Primary grantee or grantee refers to the administrative entity (such as the state, tribal entity, or
jurisdiction) receiving SPF-Rx funds for delivery of prescription drug misuse 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-Rx 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.
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Section 1: Administrative Survey
[GRANTEES SKIP TO QUESTION 7 AND COMPLETE TARGETED POPULATIONS AND
OUTCOMES SUBSECTION]
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-Rx program.
Organization Type (Subrecipients only)
Subrecipient Name (System prefill) (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-Rx program. (Select the
one response that best describes your organization.) B, F
We are a community coalition. (If selected, you will skip Question 2.)
Local public health/mental health government agency responsible for substance abuse
prevention
Local health/mental health care service provider or facility (e.g., local hospital, community
mental health center)
Youth-focused local grassroots or community-based service or advocacy organization (e.g.,
local chapter of Students Against Destructive Decisions [SADD], local youth councils)
Non-youth-focused, local grassroots or community-based service or advocacy organization
(e.g., substance abuse prevention organizations, YMCAs)
Faith-based organization
School or school district
Law enforcement organization
College or university
Tribal entity or organization
Other government agency, not listed above
Other nonprofit organization, not listed above
Other (Describe.) __________________________________________________________
2.
Are you partnering with a community coalition (an existing group that brings together diverse
organizations and individuals to collaborate on shared prevention goals)? 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-Rx funding. (Select one
response.) B, F
Yes
No
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
PFS Funding History (Subrecipients only)
3.
Has your subrecipient organization (i.e., entity that will be carrying out the activities of the
SPF-Rx) received SPF SIG or PFS funding? (Select one response.)B
Yes, SPF SIG only (If selected, you will skip Question 4.)
Yes, PFS only (If selected, you will skip Question 4.)
Yes, both SPF SIG and PFS (If selected, you will skip Question 4.)
No
Don’t know
4.
Has your subrecipient organization (i.e., entity that will be carrying out the activities of the
SPF-Rx) been part of a coalition or group or organizations that received SPF SIG or PFS
funding in the past? (Select one response.)B
Yes, SPF SIG only
Yes, PFS only
Yes, both SPF SIG and PFS
No
Don’t know
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Section 2: Strategic Prevention Framework
This section asks for information related to the Strategic Prevention Framework steps. You will be
asked to describe your activities related to the following:
■
Needs, target populations, and resources assessments;
■
Capacity building and sustainability;
■
Prevention intervention implementation; and
■
Monitoring and evaluation.
Section 2A. Needs, Target Populations, and Resources Assessments
[GRANTEES SKIP TO QUESTION 7, TARGET POPULATIONS AND OUTCOMES]
Needs Assessment (Subrecipients only)
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. The section also asks about the consumption patterns,
consequences, intervening variables, and populations you identified to target for your SPF-Rx
activities. Finally, this section includes questions about policies that have been developed that
address health disparities.
5.
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.E
Yes
No
Data Sources (Subrecipients only)
This set of questions asks about the availability of community-level 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-level data that are available to
your subrecipient community.
Under each of the categories Consumption, Consequence, and Intervening Variables, list the
data sources, including local surveys and administrative data collection systems, that are currently
available for your subrecipient community.
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
6.
For each of the types of data listed below, check the boxes to indicate (a) whether or not you
have access to the data at the community level (or closest available substate area), and
(b) whether you used the data to conduct your community needs and resources assessment.
(Note that the geographic unit available to your community might vary depending on the data
source; for example, opioid mortality or PDMP data may be available at the county or district
level, but a subrecipient could cover a smaller geographic area.)E (autofill once completed initially)
Have
access to
communitylevel data
Data Type
The data were
used for
needs
assessment
Yes
No
Yes
No
6.1. Prescription drug misuse in the past 30 days or past
year
6.2
6.3. Lifetime prescription drug misuse (ever misused)
6.4. Lifetime prescription painkiller misuse (ever misused)
6.5. Other (Describe.) _____________________________
6.6. If yes to consumption data, for what geographic level?
(Choose one)
Community County
District Region
Other
Consumption
Prescription painkiller misuse in the past 30 days or
past year
Have
access to
communitylevel data
The data were
used for
needs
assessment
Yes
No
Yes
6.7. Rate of registration of physicians with prescription drug
monitoring program (PDMP)
6.8. Use of PDMP by physicians (number of queries;
percentage of physicians making queries)
6.9. Opioid prescribing rates (from PDMP data)
6.10. Rates of high dose opioid prescribing (e.g.,
>90MME/day or >100MME/day)
6.11. Rates of opioid and benzodiazepine co-prescribing
6.12. Rates of multiple prescriber episodes for opioid pain
medication (as indicator of possible “doctor shopping”)
6.13. Rates of multiple pharmacy episodes for opioid pain
medication
6.14. Other PDMP measure of opioid prescribing
(Describe.)_______________________________
6.15. Consumers’ perceived risk of prescription drug misuse
6.16. Parent/peer attitudes about prescription drug misuse
6.17. Communication with parents about drug use
Intervening Variables
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
6.18. Social availability (e.g., through friends or family
members)
6.19. Physicians’ attitudes and knowledge
6.20. Law enforcement practices (e.g., to address diversion;
having police use Narcan to prevent overdose)
6.21. Other (Describe.) _____________________________
6.22. Mortality rates due to opioid overdose
6.23. Emergency department visits/hospital admissions
related to opioid misuse
6.24. If yes to emergency department or hospital admissions
data (item 6.23), for what geographic level? (Choose
one)
Community County
District Region
Other
Consequences
Have
access to
communitylevel data
The data were
used for
needs
assessment
Yes
No
Yes
No
6.25. Calls to poison center related to opioid misuse
6.26. Other (Describe.) _________________________
6.27. Prescription drug monitoring program (PDMP) data
6.28. Geographic data related to local patterns of opioid
overdoses
6.29. Hospital data on opioid overdose-related emergency
department visits
6.30. Hospital data on opioid overdose-related admissions
6.31. Middle school survey data about prescription/pain drug
misuse
6.32. High school survey data about prescription/pain drug
misuse
6.33. College survey data about prescription/pain drug
misuse
6.34. Community surveys about prescription/pain drug
misuse
6.35. Community survey of health care providers
6.36. Census data for community demographics
6.37. Key informant interviews or focus groups
6.38. Public meetings or forums (e.g., town hall meetings)
6.39. Other (Describe.) _________________
Data Sources
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Targeted Populations and Outcomes (Both grantees and subrecipients complete)
This set of questions asks about the specific targets your community, state, tribal entity, or
jurisdiction has identified for your SPF-Rx efforts. These targets may include specific consumption
patterns, consequences, risk and protective factors (intervening variables), or subpopulations. (Note:
Grantees should report their overall targets for their state, jurisdiction, or tribal area) Complete at
baseline and update annually if you have any changes.
7.
Indicate the consumption pattern(s) you are targeting for your SPF-Rx activities. (Select all
that apply.)E (autofill once completed initially)
Have not identified a consumption pattern to target
Nonmedical use of prescription drugs by youth age 12 to 17
Nonmedical use of prescription pain medicine by youth age 12 to 17
Nonmedical use of prescription drugs by young adults age 18 to 25
Nonmedical use of prescription pain medicine by young adults age 18 to 25
Nonmedical use of prescription drugs by all adults age 26 and over
Nonmedical use of prescription pain medicine by all adults age 26 and over
Other consumption pattern (Describe.) __________________________________________
8.
Indicate the consequence(s) you are targeting for your SPF-Rx activities. (Select all that
apply.)E (autofill once completed initially)
Have not identified a consequence to target
Emergency department visits or hospitalizations related to prescription drug overdose
Emergency department visits or hospitalizations related to opioid overdose
Poisoning center calls related to prescription drugs/opioid overdoses
Prescription drug-related deaths
Opioid-overdose related deaths
Motor vehicle crashes related to prescription drug or opioid misuse
Crime related to prescription drug or opioid misuse
Other consequences (Describe.) ______________________________________________
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
9.
Indicate the population(s) you will be focusing on for your SPF-Rx prevention activities. In the
first column, 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. (Note: If you are targeting the whole community or jurisdiction, then choose that
answer option [9.1], and do not check all the subpopulations.)
In the second column, check any specific subpopulation your SPF-Rx prevention activities
are focused on to reduce prescription drug misuse-related behavioral health disparities.
(These categories are not mutually exclusive. Use your judgment to select all responses that
describe your population of focus.)E (autofill once completed initially)
Check if you
are specifically
focusing on
this
subpopulation
Check if this
subpopulation
represents your
behavioral health
disparities
population of
focus
N/A
9.2.
We are targeting community-wide or statewide
population, not any specific subpopulations
Males
9.3.
Females
9.4.
Lesbian/gay/bisexual/transgender/questioning
(LGBTQ)
9.5.
African American
9.6.
American Indian/Native American
9.7.
Alaska Native
9.8.
Asian/Pacific Islander
9.9.
Hispanic
9.10. White
9.11. Age 12–17
9.12. Age 18–25
9.13. Age 26 and over
9.14. Other age group (Describe.) ___________________
9.15. Middle school students
9.16. High school students
9.17. College students
9.18. Parents
N/A
9.19. Current or former military or military families
9.20. Individuals living in poverty
Population
9.1.
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
9.21. Individuals whose native language is other than
English
9.22. Individuals with low literacy
9.23. Individuals with mental illness
9.24. Individuals with disabilities (e.g., hearing, visually, or
physically impaired)
9.25. Physicians/health care providers/prescribers
N/A
9.26. Pharmacists/dispensers
N/A
9.27. Other population of focus (Describe.)
_______________________________________
9.28. Other population of focus (Describe.)
_______________________________________
9.29. Other population of focus (Describe.)
_______________________________________
10.
Indicate the intervening variable(s) you will be targeting for SPF-Rx prevention. (Select all that
apply.)E (autofill once completed initially)
Have not yet selected an intervening variable to target
Laws related to prescription drugs
Level of enforcement
Social access (e.g., through friends or family members)
Physician/prescriber registration with prescription drug monitoring program
Physician/prescriber use of prescription drug monitoring program (increased queries)
Rate of opioid prescribing
Rate of high dose (>90 MME/day) opioid prescribing
Rate of multiple prescriber episodes for opioid pain medications (or other indicators of
possible “doctor shopping”)
Norms—perceived parent or peer attitudes or both (towards prescription drug misuse)
Norms—perceived peer or friend misuse of prescription drugs
Perceived risk of harm of prescription drug misuse
Perceived risk of getting caught misusing prescription drugs (e.g., by parents or law
enforcement)
Family communication around prescription drug misuse
Resistance or life skills or both
Availability of prosocial activities
Other intervening variable (Describe.) __________________________________________
Other intervening variable (Describe.) __________________________________________
Other intervening variable (Describe.) __________________________________________
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
11.
How would you describe the community or communities that you are targeting for your SPFRx prescription drug misuse prevention activities? (Select all that apply.)E (autofill once completed
initially)
Entire state/jurisdiction
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.) __________________________________________________________
[GRANTEES SKIP TO SECTION 2D. PREVENTION INTERVENTION IMPLEMENTATION]
Section 2B. Capacity Building and Sustainability (Subrecipients only)
In this section, we ask you about your activities related to capacity and sustainability. Capacity refers
to the quality and level of skills (e.g., workforce) and resources needed to achieve a desired
outcome. For SPF-Rx, capacity refers to the demonstrated ability of subrecipients to effectively
implement each SPF step (i.e., assess needs, build capacity, plan, implement, and evaluate) 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 prescription drug misuse 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 prescription drug
misuse prevention, and ensuring that prevention intervention activities and outcomes continue after
SPF-Rx funding ends.
Current Capacity (Subrecipients only)
12.
How would you rate the current capacity of your organization in the following areas for SPFRx prevention efforts? (Note: At baseline, the questions should be answered with regard to
your organization’s capacity at the time the SPF-Rx grant was awarded.) E
How much would you agree or disagree that your
organization currently has enough capacity in each of
the following areas to effectively implement your
SPF-Rx prevention efforts?
Strongly
disagree
Disagree
Agree
Strongly
agree
12.1. Capability and experience using the 5 SPF steps
12.2
12.3. Experience working with health care providers and
pharmacists for prescription drug misuse prevention
12.4. Experience with relevant interventions for prevention
of prescription drug misuse
12.5. Experience collaborating with other organizations on
interventions to prevent prescription drug misuse
12.6. Capability to use prescription drug monitoring
program (PDMP) data for prevention planning and
surveillance
Experience with the target populations for
prescription drug misuse prevention
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
12.7. Capability to use PDMP data for prevention
evaluation
12.9. Staff with the right skills to effectively implement
SPF-Rx prevention efforts
12.10. Enough staff to effectively implement SPF-Rx
prevention efforts
12.11. Enough fiscal/financial resources to effectively
implement SPF-Rx prevention efforts
12.12. Capability to sustain the prevention efforts over time
12.8
Capability to combine PDMP with other data
sources (e.g., overdose data) for prevention
planning
Training and Technical Assistance (Subrecipients only)
13.
Select the area(s) in which you needed, requested, and/or received SPF-Rx-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-Rx activities.
(Select all that apply.) E
Needed or
need T/TA in
this area
Received
T/TA in this
area
13.1. Needs and resource assessment
13.2. Using prescription drug monitoring data for prevention
assessment, planning, and monitoring
13.3. Using other data sources for prescription drug misuse
prevention efforts
13.4. Opioid addiction and epidemiology, including risk and
protective factors
13.5. Prescription drug misuse/abuse prevention
13.6. Strategic plan development
13.7. Staff, task force, or coalition member training
13.8. Building collaborative relationships with stakeholders and
partner agencies
13.9. Working with medical and pharmaceutical communities to
prevent prescription drug misuse
13.10. Working with organizations to help them establish or
implement polices to reduce risk of prescription drug misuse
(e.g., incorporation of national CDC prescribing guidelines
into health care providers’ rules and codes)
13.11. Developing strategies to enhance PDMP use
13.12. Working with law enforcement to prevent prescription drug
misuse
13.13. Intervention selection
Training/technical assistance (T/TA) areas
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
13.14. Participant recruitment
13.15. Intervention implementation
13.16. Intervention adaptation
13.17. Cultural competence
13.18. Behavioral health disparities
13.19. Evaluation
13.20. Sustainability
13.21. Public policy (e.g., collaborating to inform or implement policy
change)
13.22. Social marketing/social media/public education
13.23. Environmental strategies to prevent prescription drug misuse
13.24. Strategies to increase safe storage and disposal of
prescription drugs
13.26. Other ethical issues related to prevention work
13.27. Other (Describe.) __________________________________
13.28. Other (Describe.) __________________________________
13.29. Other (Describe.) __________________________________
13.25. Privacy issues related to data use, including HIPAA
Development of SPF-Rx Organizational Resources (Subrecipients only)
This section collects information on the activities you conducted to improve your SPF-Rx
organizational resources, such as writing mission or vision statements, identifying goals and
activities, training staff and collaborators, and creating an advisory board.
14.
Have you conducted activities that produced gains in your SPF-Rx organizational resources
or capabilities related to SPF-Rx during the past year? These could include such activities
as identifying organizational goals, improving staff and resources, and coordinating data
collection. (Select one response.)E
Yes
No (If selected, you will skip Question 15.)
15.
Indicate the activity or activities you conducted during the past Federal fiscal year that
produced gains in your SPF-Rx organizational resources. (Select all that apply.)E
Did not engage in activities that increased organizational resources during this reporting
period
Wrote or revised organizational or coalition mission or vision statement
Created an advisory board
Identified coalition leaders (if there is a coalition)
Recruited new community partners
Identified key organizational or coalition activities and goals
Increased staffing
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Trained staff or coalition members on use of prescription drug monitoring program data for
prevention
Trained staff in other areas related to prescription drug misuse prevention
Trained coalition members
Improved cultural competence for SPF-Rx populations of focus
Secured additional funding
Secured physical space
Established a dedicated community assessment team
Modified or developed data systems (for prescription drug prevention efforts
Other: (Describe.) __________________________________________________________
16.
Below is a list of funding sources that could be used to support prevention of prescription drug
misuse. Please check the box in the column next to the funding source if your organization
has used funding from this source to support SPF-Rx-related activities during the past
Federal fiscal year. Consult with your SPF-Rx grantee if you are unsure of some of these
funding sources. Do not include funding received by other organizations in your coalition or
group, unless those funds are used for SPF-Rx-related activities.E
Do you use any funding
from this source to support
SPF-Rx-related activities?
Source of funding/resources
YES
NO
16.1. SPF-Partnerships for Success (PFS) (SAMHSA)
16.2. Substance Abuse Prevention and Treatment Block
Grant (SAMHSA)
16.3. SAMHSA Prescription Drug Overdose Prevention grant
16.4. SAMHSA Medical-Assisted Treatment (MAT)
16.5. CDC Prevention for States (PfS)
16.6. CDC Data-Driven Prevention Initiative (DDPI)
16.7. BJA Harold Rogers PDMP
16.8. SAMHSA Minority HIV/AIDS Initiative
16.9. HRSA Rural Opioid Overdose Reversal (ROOR)
16.10. Drug-Free Communities (DFC) grant
16.11. Medicaid (Federal, state, local)
16.12. Other Federal funds (Describe.)
_______________________________________
16.13. Other state/tribal/jurisdiction funds (Describe.)
_______________________________________
16.14. Other local government funds (Describe.)
_______________________________________
16.15. Foundations/nonprofit organizations
16.16. Corporate/business entities
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
16.17. Individual donations/funding from fundraising events
16.18. Other (Specify.)
_______________________________________
Relationship Building (Subrecipients only)
This section collects information on partners you identified to join your SPF-Rx partnership or
participate in planning and prevention intervention activities.
17.
Have you identified key stakeholders, partners, and partner organizations to participate in
your SPF-Rx planning and prevention intervention activities? This includes coalition members
if you are working with a coalition. (Select one response.)E
Yes
No (If selected, you will skip Question 18.)
Program Evaluation for Prevention Contract (PEP-C) February 2017
18
Provide more information on the key stakeholders, partners, and partner organizations that participate in your organization’s SPF-Rx
activities. This may include a combination of individuals and organizations. “Active” stakeholders/partners demonstrated support or
participation in your activities and interventions during the past year. (Note: If you have identified key stakeholders and partners but
they are not active yet, count them as representatives in the first column, but do not count them as “active” in the subsequent
columns.).E (autofill column 2 after initially completed)
Sector
18.1. Physicians/health care providers or health care
organizations (excluding hospitals/hospital staff)
18.2. Hospital medical staff or hospital organization
18.3. Dentists or dental organizations
18.4. Pharmacists/pharmacy organizations
18.5. Substance abuse prevention
professionals/organizations
18.6. Substance abuse treatment
professionals/organizations
18.7. Mental health professionals/agencies
18.8. Insurance professionals or organizations
18.9. Youth groups/representatives
18.10. Schools/school districts
18.11. Colleges and universities
18.12. Other youth-serving professionals/organizations
18.13. Parents/family/caregiver groups
18.14. Tribal leaders or elders
18.15. Business community
18.16. Workers compensation programs
18.17. Media (radio/TV stations; newspapers)
18.18. Clergy/faith-based organizations
18.19. Civic or volunteer organizations/professionals
How many
representatives
from this sector are
key stakeholders or
partner members in
your SPF-Rx
activities?
How many of
these key
stakeholder or
partner
members were
“active” during
the past year?
What was the average level of
involvement for the members of
this sector in your SPF-Rx
activities during the past year?
(Mark only if # active partners >0)
Low
Medium
High
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Program Evaluation for Prevention Contract (PEP-C) February 2017
18.
19
Organizations/individuals serving LGBTQ population
Military professionals/agencies
Law enforcement professionals/agencies
Courts/judiciary system professionals/agencies
Other state, local, or tribal government agencies
Other organizations/sectors (Describe.)
_____________
18.26. Other organizations/sectors (Describe.)
_____________
18.27. Other organizations/sectors (Describe.)
_____________
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Program Evaluation for Prevention Contract (PEP-C) February 2017
18.20.
18.21.
18.22.
18.23.
18.24.
18.25.
20
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Data Infrastructure (Subrecipients only)
19.
Did your community have access to community-level PDMP data/reports for prevention
planning prior to the SPF-Rx grant?B (Baseline)
Yes, we had access, but did not normally use PDMP data for prevention
Yes, we had access and normally used PDMP data for prevention planning
No, we did not have access to PDMP data
20.
During the past fiscal year, approximately how often did you receive updated PDMP
data/reports for your SPF-Rx target communities (or the closest available substate area)?
(Select one)E
Did not receive any PDMP data/reports in the past fiscal year
Once
Semi-annually (twice per year)
Quarterly
Every other month
Monthly
Other (Specify.) ___________________________________________________________
21.1. For what geographic area are PDMP data/reports available to you? (Select all that apply.)E
PDMP data are not available to us yet
Community
County
District
State
Other (Specify.) ____________________________________________________________
21.2. Are privacy or HIPAA concerns a major barrier to receiving community-level PDMP reports?E
(update annually only if it changes)
Yes
No
22.
How has your access to and use of community-level PDMP data/reports as part of your SPFRx effort affected your local prevention efforts? (Select all that apply.) F (Final)
We did not get access to any community-level PDMP data/reports during the grant
We had access to community-level PDMP data/reports, but we were not able to use them
PDMP data did not significantly change our prevention approach
PDMP data changed our understanding of the problem
PDMP data guided local prevention strategies in new directions
PDMP data enabled us to better monitor risky prescribing and dispensing patterns
PDMP data informed enforcement efforts in new ways
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Other (Describe.) __________________________________________________________
23.
In this reporting period, how have you worked to develop or enhance data infrastructure
needed for data-driven needs assessment, planning, monitoring, and evaluation? (At
baseline, this question refers to the time before you received SPF-Rx funding; at follow-up it
refers to your SPF-Rx funding period. Select all that apply.)E
Not applicable; no work was done to enhance data infrastructure during this reporting period
Developed or enhanced procedures for accessing prescription drug monitoring program
(PDMP) data/reports
Developed or enhanced procedures for accessing hospital data
Developed or enhanced procedures for accessing data from other agencies (e.g., vital
statistics, Census)
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)
Created or enhanced a local database to house community surveillance data
Developed procedures for participation in a state/tribal/jurisdiction database
Enhanced skills or expertise of local stakeholders to use PDMP data…
How did you enhance skills or expertise of local stakeholders to use PDMP data?
(Check all that apply)
For development of local strategies and interventions (e.g., with medical and
pharmacy communities)
For surveillance and performance monitoring
Other (Describe.)________________________________________________
Developed procedures for utilizing PDMP data provided by the state/tribal entity/jurisdiction
Developed or enhanced standardized prescription drug/opioid misuse surveillance reports
Other (Describe.) ___________________________________________________________
Sustainability (Subrecipients only)
This section asks about things you have done to ensure that SPF-Rx related prevention intervention
activities and outcomes continue once SPF-Rx funding ends. These efforts might focus on ensuring
continued funding, structures, networks, partnerships, leadership, and resources.
24.
During the past Federal fiscal year, how have you worked to ensure that prescription drug
misuse prevention intervention activities and outcomes continue after SPF-Rx funding has
ended? (Select all that apply.)E
Not applicable; no work was done in the past year to ensure that prescription drug misuse
prevention intervention activities and outcomes continue after SPF-Rx funding has ended.
Leveraged, redirected, or realigned other funding sources or in-kind resources (e.g., used
the success of the SPF-Rx efforts to secure other funds)
Worked to ensure that prescription drug misuse prevention intervention activities are
incorporated into the missions/goals and activities of other organizations (e.g., medical
boards, local pharmacies, school districts, law enforcement agency)
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Worked to ensure that prescription drug misuse prevention staff positions are folded into
other organizations (e.g., health departments, school districts, community agencies)
Worked to gain formal adoption of prescription drug misuse prevention intervention activities
into other organizations’ practices (e.g., health care provider organizations, pharmacies,
medical school curriculum, school district curriculum, organizational policy change)
Worked to inform, help implement, or provide education related to new laws, policies, or
regulations to guarantee the continuation of prescription drug misuse prevention intervention
activities or outcomes
Worked on developing a prescription drug misuse partnership structure that will continue to
function beyond the end of the SPF-Rx grant period
Worked to create sustainable data infrastructure and staffing to continue to monitor PDMP
and other surveillance data after SPF-Rx grant ends
Other (Describe.) __________________________________________________________
Section 2C. Prevention Intervention Implementation (Both grantees and
subrecipients complete)
This section collects information about the prevention interventions you selected for implementation
in your service area. A prevention intervention is an activity or set of activities to which a group or
community is exposed to change their behavior. For SPF-Rx, these activities should aim to prevent
or lower the rate of prescription drug misuse and abuse 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 prescription drug misuse 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
Annual Implementation Instrument manual for more information.
25.
Did you or your community partners deliver any SPF-Rx related prevention interventions
during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 26 through 124.)
Program Evaluation for Prevention Contract (PEP-C) February 2017
23
26.
Name all the prevention interventions you or your partners delivered during this reporting period as part of your SPF-Rx efforts.
Refer to the Annual Implementation Instrument Manual before you complete the information in this section. That 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 year. The CSAP strategy type will determine a subset of questions you must
complete for the prevention intervention and service type.
26.1.
Intervention
name
From the dropdown menu,
select the
name of each
prevention
intervention
you are
implementing,
or select
“other” and
write in the
name
26.3. Service
26.2. Service type type name
From the dropWrite in the
down menu, select name of the
the service type for specific set of
each major set of services or
services or
activities that
activities you are
you
implementing
implemented
under this
as part of your
prevention
intervention if
intervention, or
this name
select “other” and differs from
write in the name. the service
Many strategies
type label
may consist of only
one service type.
26.4. Date
started
Date you
began funding
this
interventionservice type
through your
SPF-Rx
initiative
(MM/YYYY)
26.5. CSAP strategy
type
Select the CSAP
strategy type that best
describes this
intervention-service
type:
Community-based
processes
Prevention
education (of the
public)
Alternative
activities
Problem
identification and
referral
Environmental
strategy
Information
dissemination (and
other
communication
activities)
26.6. Institute of
Medicine (IOM)
category
Select the IOM
category for this
interventionservice type:
Universal
direct
Universal
indirect
Selective
Indicated
26.9. Date
completed or
26.7. Intervention targets
26.8. Status
discontinued
Select the option that best
Check
For interventiondescribes the targets of this whether the
service types
intervention-service type:
intervention- completed or
service type
discontinued
Individuals
was Active,
during the past
Families (individuals’
Inactive,
year, indicate the
immediate social
Completed, or date completed or
environments)
Friends/peers (individuals’ Discontinued discontinued
during the
(MM/YYYY)
immediate social
past
year
environments)
Schools (institutions
serving young people)
Medical community
Pharmacy community
Other institutions or
organizations that serve
or influence targeted
individuals
Whole communities or
state/jurisdiction
Public laws or policy
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Program Evaluation for Prevention Contract (PEP-C) February 2017
Implemented Prevention Interventions
24
26.1. Intervention
name
26.2. Service
type
26.3. Service
type name
26.4. Date
started
26.5. CSAP strategy
type
26.6. Institute
of Medicine
(IOM) category
26.9. Date
completed or
discontinued
26.7. Intervention targets 26.8. Status
Medical community
Completed
09/2016
Health care
Training/
provider training on educating
using PDMP data environmental
influencers
03/2013
Training/
educating
environmental
influencers
Environmental
Universal
indirect
Name of your
media campaign
Media
campaigns
05/2016
Information
Dissemination
Universal direct Whole communities
Incomplete
10/2013
Changing
policies,
regulations, or
laws
Environmental
Universal
indirect
Medical community
Completed
01/2014
Environmental
Media
campaigns
Mandating provider Changing
training on safe
policies,
opioid prescribing regulations, or
laws
Prescription Drug
Drop Boxes
Prescription Drug Prescription
Drop Boxes
Drug Drop
Boxes
12/2016
Policy
instituted:
Yes / No
Universal
indirect
Other Institutions or
Organizations
Complete
01/2016
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Program Evaluation for Prevention Contract (PEP-C) February 2017
Sample Table:
25
SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Prevention Intervention and Service Type Information
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Intervention questions
27.1. 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)
Nonmedical use of prescription drugs/pain medication by youth age 12 to 17
Nonmedical use of prescription drugs/pain medication by young adults age 18 to 25
Nonmedical use of prescription drugs/pain medication by young adults age 26 and over
Prescription drug/opioid-related deaths
Emergency department visits or hospitalizations related to prescription drug/opioid overdose
Poisoning center calls related to prescription drug/opioid overdoses
Motor vehicle crashes related to prescription drug or opioid misuse
Crime related to prescription drug or opioid misuse
Other consumption pattern or consequence (Describe.) ____________________________
Other consumption pattern or consequence (Describe.) ____________________________
27.2. 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 or regulations related to PDMP data (access, use, timeliness, or quality)
Laws or policies related to prescriber or dispenser training or practices
Other laws or policies related to prescription drugs/pain medications
Rate of registration of physicians with prescription drug monitoring program (PDMP)
Use of PDMP by physicians (number of queries; % of physicians making queries)
Opioid prescribing rates (from PDMP data)
Rates of high dose opioid prescribing (>90MME/day)
Rates of multiple prescriber episodes for opioid pain medication (as indicator of possible
“doctor shopping”)
Rates of multiple pharmacy episodes for opioid pain medication
Law enforcement practices
Social access/availability (e.g., through family and friends)
Norms—perceived parent or peer attitudes or both
Norms—perceived peer use
Consumers’ perceived risk of harm of prescription drug misuse
Consumers’ perceived risk of getting caught
Family communication around prescription drug misuse
Resistance or life skills or both
Availability of prosocial activities
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Other intervening variable (Describe.) __________________________________________
Other intervening variable (Describe.) __________________________________________
Other intervening variable (Describe.) __________________________________________
28.1. To your knowledge, is this intervention a promising or evidence-based program, policy, or
practice? (A promising practice has strong quantitative and qualitative data showing positive
outcomes, but it does not yet have enough research or replication to support generalizable
positive public health outcomes. An evidence-based intervention has been rigorously
evaluated and replicated with demonstrated effects.) (Select one response.)E (autofill after first
completed)
Yes
No
Don’t know
28.2. How did you select your intervention? (Select all that apply.)E (autofill after first completed)
Inclusion in a Federal registry of evidence-based interventions
Found to be effective (on the primary targeted outcome) in a published, scientific journal
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)
Recommended by evidence-based practice workgroup (EPBW)
Appeared on a list of recommended promising or evidence-based programs, policies, and
practices provided by our state, tribal entity, or jurisdiction
Recommended by the SPF-Rx grantee (state, tribe, or jurisdiction) but not on a formal list of
promising or evidence-based programs, policies, and practices
Is based on guidelines, protocols, standards, or preferred practice patterns that have been
proven to lead to effective prevention outcomes
Based on a theory of change that is documented in a clear logic or conceptual model
Other (Describe.) __________________________________________________________
29.
Have you renamed the existing promising or 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
30.
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 SPF-Rx funding
Continuation of a SPF-SIG or PFS prevention intervention
Continuation of a non-SPF-SIG and non-PFS prevention intervention
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
31.
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 population of
focus) in the past Federal fiscal year? (Select one response.)E
Yes (Describe.) ____________________________________________________________
No
Service type questions
Name of Prevention Intervention: _________________________________ (autofill from Question 26)
Service Type: ___________________________________________ (autofill from Question 26)
32.
For Questions 32.1 through 32.7, indicate the locations and population of focus being served
by this prevention intervention-service type. You are required to include ZIP codes
(Question 32.4) for all locations being served by this prevention intervention-service type. For
Question 32.4, if your target population is the entire state or county, you may enter
“statewide” or “county-wide,” (along with the name of the county in Question 32.3). If you are
implementing in separate settings (e.g., schools, workplaces), list each setting separately.
(Note: If you are implementing a media campaign that reaches the whole county, you may
enter “county-wide” for location (Question 32.1).)
Use one line to describe each location served by the intervention-service type. Other than ZIP
code (Question 32.4) and estimated target population (Question 32.7), you need to complete
only those categories that are appropriate for this prevention intervention-service type and
community served.E (autofill after first completed)
32.1.
Location
(e.g.,
school
name,
business,
community
center)
32.2.
City/town
32.3.
County/
parish
32.4.
ZIP
codes
32.5. Other
geographic
descriptor
(e.g.,
neighborhood,
development)
Describe—500character limit
32.6. Target
population
description
Describe—
500character
limit
32.7. 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 20year-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
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
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.
33.
How many of your key stakeholders, partners, and partner organizations supported or
partnered with you on this prevention intervention-service type during the past year?
Indicate the number or organizations and number of individuals who partnered with you on
this prevention intervention-service type from each sector.E
33.1. Sectora
aSectors
33.2. Number of organizations
33.3. Number of individuals
will be prepopulated in this table on the basis of responses to Question 18.
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Community-Based Processes Sub-Form
Name of Prevention Intervention: _________________________________ E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
34.
For this intervention-service type, 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 funds for prescription misuse prevention) during the past year? E
Yes
No (If selected, you will automatically proceed to the end of this sub-form.)
35.
Indicate the number of stakeholder/partner meetings you held during the past year for this
intervention-service type, if any. This response should be written as a whole number (e.g.,
4).E
Meetings (If none, enter ‘0.’)
36.
Indicate the number of stakeholders/partners you trained during the past year for this
intervention-service type, if any. This response should be written as a whole number (e.g.,
4).E
Stakeholders/partners trained (If none, enter “0.”)
37.
Indicate the number of community members, other than stakeholders/partners, you trained
during the past year for this intervention-service type, if any. This response should be
written as a whole number (e.g., 4).E
Community members trained (If none, enter “0.”)
38.
Indicate the number of community organizations to whom you provided training or technical
assistance during the past year for this intervention-service type, if any. This response
should be written as a whole number (e.g., 4).E
Community organizations (If none, enter “0.”)
39.
Did you develop a prescription drug misuse prevention provider network during the past
year for this intervention-service type? For example, you may have established a prescriber
and dispenser group that meets regularly. (Select one response.)E
Yes
No, we do not yet have a network
No, a network was already in place
Program Evaluation for Prevention Contract (PEP-C) February 2017
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
40.
For this intervention-service type, during the past year, did you help with reorganizing
agencies to promote efficiency in delivering prescription drug misuse prevention services?
(Select one response.)E
Yes
No
41.
For this intervention-service type, during the past year, did you reallocate other (non-SPFRx) sources of funding to help support the goals of your SPF-Rx effort? (Select one
response.)E
Yes
No
42.
For this intervention-service type, during the past year, did you formally change the ways
organizations work together to prevent prescription drug misuse —for example, by
documenting specific policies or practices for working together? (Select one response.)E
Yes
No
43.
For this intervention-service type, did you conduct other community activities during the past
year? (Select one response.)E
Yes (Describe.) ____________________________________________________________
No
44.
Estimate the total number of individuals in your target population who were reached or
affected by this community-based process intervention-service type during the past Federal
fiscal year. Out of the total target population you reported in Question 32.7, approximately
how many individuals were affected by the results of this intervention-service type? (Note:
Because this is a population-based intervention, you are asked to estimate the number of
people reached. For direct service interventions, such as prevention education, you will be
asked to report the number directly served.)E
(Prepopulate: Total targeted population reported in item 32.7: ___________________)
Enter the estimated number of individuals in the target population reached or affected by
this intervention-service type. (If none, enter “0”—you will automatically proceed to the
end of this sub-form.) _____________________
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The next few questions ask for demographic information about the individuals reached by your
community-based processes. (Note that if you are targeting an entire geographic area (e.g., county
or zip codes), you can use available Census data to estimate some of the demographic
characteristics of individuals you reached. For example, if you estimate that you reached 10% of
your target population, then the number of males and females would be 10% of the total Census
estimates for that geographic area.)
45.
Of the total number of participants who were reached or affected by this community-based
process intervention-service type during the past year (reported in Question 44), 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 44. This response
should be written as a whole number (e.g., 4) and not as a percentage.E
45.1. Females: ______________________________
45.2. Males: ________________________________
45.3. Transgender: __________________________
45.4. Other: _____________________________ (Specify: _________________________)
45.5. Gender unknown: _______________________
46.
Of the total number of participants were reached or affected by this community-based
process intervention-service type during the past year (reported in Question 44), 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 44.
This response should be written as a whole number (e.g., 4) and not as a percentage.E
46.1. Children age 0 to 11: _____________
46.2. Youth age 12 to 17: ______________________
46.3. Young adults age 18 to 25: ________________
46.4. Adults age 26 and older: __________________
46.5. Age unknown: __________________________
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47.
Of the total number of participants reached or affected by this community-based process
intervention-service type during the past year (reported in Question 44), 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 reached or
affected 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 44. This response should be
written as a whole number (e.g., 4) and not as a percentage.E
47.1. American Indian or Alaska Native: _____________
47.2. Black or African American: _____________
47.3. White: _____________
47.4. Asian: _____________
47.5. Native Hawaiian or Other Pacific Islander: ______________
47.6. Multiracial: ___________
47.7. Other: _____________
47.8. Race unknown: ___________
48.
Of the total number of participants reached or affected by this community-based process
intervention-service type during the past year (reported in Question 44), indicate how many
were Hispanic/Latino and how many were non-Hispanic/Latino. The number of NonHispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants
reported in Question 44. This response should be written as a whole number (e.g., 4) and not
as a percentage.E
48.1. Hispanic, Latino/a, or of Spanish origin: ____________
48.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
48.3. Hispanic ethnicity unknown: ____________
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Prevention Education Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
This sub-form is for prevention education of the public, which might include students, parents,
employees, members of the military, and other groups. Training or education of environmental
influencers (e.g., health care providers, pharmacists, law enforcement officers, and school
employees) should be categorized as an environmental strategy (CSAP strategy type) and reported
in the Environmental Strategies sub-form.
49.
Indicate the type(s) of participants served by this prevention education intervention during
the past Federal fiscal year.E
49.1. Age group(s) targeted for service during the past year: (Select all that apply.)
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.)____________________________________________________
49.2. Population type(s) targeted for service during the past year: (Select all that apply.)
Middle school students
High school students
College students
Parents
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.)____________________________________________________
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50.
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 year and how many groups completed the
prevention education intervention during the past year. 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
50.1. Location (e.g., Wade Middle School)
50.2. Number of groups
started in the past year
50.3. Number of groups
completed in the past year
51.1. What was the average number of sessions provided for each group 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).E
___ sessions
51.2. 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).E
___ hours
52.
How many total participants were served by this prevention education intervention during
the past year? This response should be written as a whole number (e.g., 4).E
__________
53.
participants (If none, enter “0”—you will automatically proceed to the end of
this sub-form.)
Of the total number of participants served by this prevention education intervention during
the past year (reported in Question 52), 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 52. This response should be written as a whole number
(e.g., 4) and not as a percentage.E
53.1. Females: _____________
53.2. Males: ______________
53.3. Transgender: ______________
53.4: Other: _____________________________ (Specify: _________________________)
53.5: Gender unknown: ______________
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54.
Of the total number of participants served by this prevention education intervention during
the past year (reported in Question 52), 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 52. This response should be written as a
whole number (e.g., 4) and not as a percentage.E
54.1
Children age 0 to 11: _____________
54.2
Youth age 12 to 17: _____________
54.3. Young adults age 18 to 25: _____________
54.4. Adults age 26 and older: _____________
54.5. Age unknown: ___________
55.
Of the total number of participants served by this prevention education intervention during
the past year (reported in Question 52), 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 served 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 52. This response should be written as a whole number
(e.g., 4) and not as a percentage.E
55.1. American Indian or Alaska Native: _____________
55.2. Black or African American: _____________
55.3. White: _____________
55.4. Asian: _____________
55.5. Native Hawaiian or Other Pacific Islander: ______________
55.6. Multiracial: ___________
55.7. Other: _____________
55.8. Race unknown: ___________
56.
Of the total number of participants served by this prevention education intervention during
the past year (reported in Question 52), 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 52. This response
should be written as a whole number (e.g., 4) and not as a percentage.E
56.1. Hispanic, Latino/a, or of Spanish origin: ____________
56.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
56.3. Hispanic ethnicity unknown: ____________
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Alternative Drug-Free Activities Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
57.
Indicate the type(s) of participants served by this alternative drug-free activity during the
past Federal fiscal year.E
57.1. Age group(s) targeted for service during the past year: (Select all that apply.)
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.)____________________________________________________
57.2. Population type(s) targeted for service during the past year: (Select all that apply.)
Middle school students
High school students
College students
Parents
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.)
58.
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 59-61.)
Populations as a whole (If selected, you will complete Questions 62-63.)
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Questions for alternative activities targeted at identifiable participants
59.
In the table below, list each separate location where you implemented this alternative drugfree activity and then indicate how many groups of participants started this alternative drugfree activity during the past year and how many groups completed the alternative drug-free
activity during the past year. 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
59.1. Location (e.g., Wade
Middle School)
60.
59.2. Number of groups started
in the past year
59.3. Number of groups
completed in the past year
What was the average number of sessions provided for each group of participants in this
alternative drug-free activity during the past year? This response should be written as a
whole number (e.g., 4).E
________sessions
61.
What was the total number of hours provided for each group of participants in this
alternative drug-free activity during the past year? 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
62.
What type(s) of the alternative activity events that were not targeted to identifiable
participants did you implement during the past year? (Select all that apply.)E
Concert
Festival or fair
Sporting event
Picnic
Drop-in activity
Web-based gathering
Other (Describe.) __________________________________________________________
63.
How many separate alternative activity events that were not targeted to identifiable
participants were conducted during the past year? This response should be written as a
whole number (e.g., 4).E
__________ events
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64.
How many total participants were served or reached by this alternative drug-free activity
during the past year? 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.)
65.
Of the total number of participants served or reached by this alternative drug-free activity
during the past year (reported in Question 64), 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 64. This response should be written as a whole number
(e.g., 4) and not as a percentage.E
65.1. Females: _____________
65.2. Males: ______________
65.3. Transgender: ____________________
66.
65.4
Other: ___________________________ (Specify: __________________________)
65.5
Gender unknown: _______________
Of the total number of participants served by this alternative drug-free activity during the
past year (reported in Question 64), 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 64. This response should be written as a whole
number (e.g., 4) and not as a percentage.E
66.1. Children age 0 to 11: _____________
66.2. Youth age 12 to 17: _____________
66.3. Young adults age 18 to 25: _____________
66.4. Adults age 26 and older: _____________
66.5. Age unknown: _____________
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67.
Of the total number of participants served by this alternative drug-free activity during the
past year (reported in Question 64), 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 served 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 64. This response should be written as a whole number
(e.g., 4) and not as a percentage.E
67.1. American Indian or Alaska Native: _____________
67.2. Black or African American: _____________
67.3. White: _____________
67.4. Asian: _____________
67.5. Native Hawaiian or Other Pacific Islander: ______________
67.6. Multiracial: ___________
67.7. Other: _____________
67.8. Race unknown: ___________
68.
Of the total number of participants served by this alternative drug-free activity during the
past year (reported in Question 64), 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 64. This response
should be written as a whole number (e.g., 4) and not as a percentage.E
68.1. Hispanic, Latino/a, or of Spanish origin: ____________
68.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
68.3. Hispanic ethnicity unknown: ____________
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Problem Identification and Referral Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
69.
Indicate the type(s) of participants served by this Problem Identification and Referral
prevention intervention during the past Federal fiscal year.E
69.1. Age group(s) targeted for service during the past year: (Select all that apply.)
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.) ___________________________________________________
69.2. Population type(s) targeted for service during the past year: (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.) ___________________________________________________
70.
Where did this problem identification and referral activity take place during the past Federal
fiscal year? (Select all that apply.)E
School
Health care facilities
Jails or prisons
Courts
Workplace or workplace program
Other (Describe.) __________________________________________________________
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71.
At how many different places did this problem identification and referral activity occur during
the past year? 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
71.1. Organization or location
71.2. Number of cycles (or NA)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
72.
What type(s) of services were individuals referred to during the past year? (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.) __________________________________________________________
73.
What was the total number of individuals for whom this problem identification and referral
services were provided during the past year? 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.)
74.
Of the total number of participants provided this problem identification and referral services
during the past year (reported in Question 73), 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 73. This response should be written as a whole number
(e.g., 4) and not as a percentage.E
74.1. Females: _____________
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74.2. Males: ______________
74.3. Transgender: _____________________
75.
74.4
Other: __________________________ (Specify: ____________________________)
74.5
Gender unknown: _______________
Of the total number of participants provided this problem identification and referral services
during the past year (reported in Question 73), 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 73. This response should be
written as a whole number (e.g., 4) and not as a percentage.E
75.1
Children age 0 to 11: _____________
75.2
Youth age 12 to 17: _____________
75.3. Young adults age 18 to 25: _____________
75.4. Adults age 26 and older: _____________
75.5. Age unknown: ______________
76.
Of the total number of participants provided this problem identification and referral services
during the past year (reported in Question 73, 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 provided services to 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 73. This response should be
written as a whole number (e.g., 4) and not as a percentage.E
76.1. American Indian or Alaska Native: _____________
76.2. Black or African American: _____________
76.3. White: _____________
76.4. Asian: _____________
76.5. Native Hawaiian or Other Pacific Islander: ______________
76.6. Multiracial: ___________
76.7. Other: _____________
76.8. Race unknown: ___________
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77.
Of the total number of participants provided this problem identification and referral services
during the past year (reported in Question 73), 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 73. This response should be written as a whole number (e.g., 4) and not as a
percentage.E
77.1. Hispanic, Latino/a, or of Spanish origin: ____________
77.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
77.3. Hispanic ethnicity unknown: ____________
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Environmental Strategies Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
Throughout this section, you refers to your organization or partners with your organization.
In the remainder of this sub-form, you will be asked to report the following environmental strategy
types as relevant to your SPF-Rx activities (if applicable, you will be able to describe other types of
environmental activities at the end of this sub-form):
I.
Training and education of environmental influencers—people who are in positions to affect
prescription drug misuse and abuse through medication prescribing and dispensing
practices, communication, policy, enforcement, and so on (e.g., health care providers,
pharmacists, insurers, law enforcement officers, school employees);
II.
Policy, regulation, or law enactment or implementation (e.g., changing, implementing, or
strengthening the implementation of new laws related to safe opioid prescribing practices or
health care provider registration and use of PDMP; changing opioid training requirements for
physician credentialing or licensure; and changes to organizational codes, rules, or policies);
III.
Enforcement (e.g., collaborating with law enforcement or medical boards to develop policies
to address diversion or enforcement of pain clinic regulations); and
IV.
Other environmental strategies, such as expansion of prescription drug drop boxes in
pharmacies and distribution of home lock boxes for prescription drugs.
I.
Training and educating environmental influencers
In this section, report strategies that include providing training and individual education for those in
positions to affect prescription drug misuse and abuse through policy, prescribing and dispensing
practices, enforcement, communication, and so on (e.g., health care providers, pharmacists, law
enforcement officers, school employees). Include only training and individual education 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.
78.
Did this environmental strategy include training or individual education (e.g., “detailing”) with
environmental Influencers—those in positions to affect prescription drug misuse through
policy, enforcement, communication, and so on (e.g., health care providers, pharmacists, law
enforcement officers, school employees)? (Select one response.)E
Yes, group training of environmental influencers (answer questions 79 through 82)
Yes, individual education of environmental influencers (skip questions 80 through 81.2)
No (If selected, you will skip Questions 79 through 82.)
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79. To which types of environmental influencers did you provide training or individual education to
affect prescription drug misuse through policy, enforcement, communication, and so on
during the past year? (Select all that apply.)E (autofill after first completed)
Health care providers/medical community
Dentists/dental community
Pharmacists/pharmacy community
Insurers
School employees or administrators
Law enforcement
Other policymakers such as elected officials
Tribal leaders or elders
Business owners or employees
Service or civic organization employees or administrators
Media members
Military personnel or veterans’ organizations
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
80.1. How many groups of participants started the training of environmental influencers during the
past year? Do not include groups counted in previous reporting periods. This response
should be written as a whole number (e.g., 4).E
_________ groups started
80.2. How many groups of participants completed the training of environmental influencers during
the past year? 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
81.1. How many training sessions were conducted for each group of environmental influencers
during the past year? This response should be written as a whole number (e.g., 4).E
_________ sessions
81.2. What was the average length of the individual training sessions, in hours, during the past
year? This response should be written as a whole number (e.g., 4).E
_________ Hours
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82.
In total, how many individuals participated in group training or individual education of
environmental influencers during the past year? This response should be written as a whole
number (e.g., 4).E
_________ Individuals participated in group training
_________ Individuals educated
II.
83.
Policy, regulation, or law enactment or implementation
During the past year, did your SPF-Rx environmental strategy include any policy, regulation,
or law enactment or implementation? This would include changing, implementing, or
strengthening the implementation of new laws at the state level or working with organizations
at the local level to develop or implement policies to advance the goals of SPF-Rx (e.g., help
health care provider organization institute policies to follow CDC guidelines for prescribing
opioids). (Select one response.)E
Yes
No (If selected, you will skip Questions 84 through 89.)
84.
For this particular environmental strategy, during the past year, how many different
organizations did you collaborate with for the policy, regulation, or legal change,
establishment, or implementation? For example, if you targeted changing policies related to
opioid prescribing, count the relevant medical or governmental organizations you collaborated
with for that change. Do not count individual prescribers.E
_________ different organizations
85.1. During the past year, did you do any work related to changing or implementing laws,
regulations, government policies, or licensing requirements as part of your SPF-Rx efforts?
For example, this could involve state laws related to the use of PDMP data or to opioid
prescribing practices.E
Yes
No (If selected, you will skip Questions 85.2. and 86.)
85.2
What types of activities were you engaged in to support enactment or implementation of laws,
regulations, governmental policies, or licensing requirements? (Select all that apply.)E
Met with elected officials or policymakers to educate them on the policy issues
Conducted research or analysis of policy options for officials or policymakers
Informed key stakeholders and institutions about the new policy, law, or requirement
Coordinated activities or meetings with key stakeholders and organizations
Developed informational materials (fliers, postcards, websites) related to the new policy, law,
or requirement
Distributed informational materials (fliers, postcards, websites) related to the new
law/policy/requirement
Other activities (Specify.) ____________________________________________________
Other activities (Specify.) ____________________________________________________
Other activities (Specify.) ____________________________________________________
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86.
Indicate which of the following laws, regulations, government policies, or licensing
requirements you worked on during the past year as part of your SPF-Rx effort. Include only
activities related to the specific environmental strategy on which you are reporting in this subform. Do not include activities that are part of other environmental strategies that you have
listed as separate interventions. Note that some items will only be applicable to the primary
grantee or the subrecipient, depending on whether they are state or local types of activities.
For example, state-level grantees may be more involved in state-level legislative issues (e.g.,
PDMP laws) than subrecipient communities are.
Please check the boxes below for any changes to specific laws, regulations, government
policies, or licensing requirements that you worked on during the past year. Then indicate
whether your activities related to change (enactment) or implementation of the new law,
regulation, governmental policy, or licensing requirement. (Select all that apply.)E
Possible changes to PDMP-related policies, regulations, or laws at the state level:
Require universal prescriber registration with the PDMP
Involved with changing policy or law
Involved with implementation
Allow doctors to assign authorized delegates to access PDMP data
Involved with changing policy or law
Involved with implementation
Have state rules that delineate circumstances when prescribers must query the PDMP for
their patients’ history of opioid prescriptions
Involved with changing policy or law
Involved with implementation
Require that pharmacists upload opioid dispensing data more quickly (e.g., within 24 hours)
Involved with changing policy or law
Involved with implementation
Expand the scope of data reported to PDMP by pharmacists (e.g., source of payment)
Involved with changing policy or law
Involved with implementation
Allow expansion of PDMP data access to allow use for public health surveillance,
prevention, and research
Involved with changing policy or law
Involved with implementation
Develop interstate agreements to share PDMP data (e.g., facilitate providers’ ability to query
PDMPs of neighboring states)
Involved with developing policy
Involved with implementation of new policy
Create a linkage between patients’ PDMP records and their electronic health records
Involved with developing policy
Involved with implementation of new policy
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Other PDMP-related policy changes:
Change the algorithm by which patients with similar names and other characteristics are
aggregated
Produce regular reports from the PDMP that summarize key state or regional statistics of
interest
Involved with developing policy
Involved with implementation of new policy
Produce unsolicited reports from the PDMP
Involved with developing policy
Involved with implementation of new policy
For which group are the new unsolicited reports? (check all that apply):
Prescribers (Describe purpose.) ________________________________________
Dispensers (Describe purpose.) _________________________________________
Licensing boards (Describe purpose.) ____________________________________
Law enforcement agencies (Describe purpose.) ____________________________
Other group (Specify and describe purpose.) ______________________________
Other PDMP-related policy change (Specify). _____________________________________
Other PDMP-related policy change (Specify). _____________________________________
Possible changes to prescription related policies, regulations, or laws:
Mandate prescriber training on safe opioid prescribing
Involved with changing policy, regulation, or medical licensing board requirement
Involved with implementation of new requirement
Limit dose of opioid prescription (e.g., 90 MME/day) without special approval
Involved with changing state guidelines or state insurance/Medicaid pharmacy
policy
Involved with implementation of new guidelines/policies
Limit duration of opioid prescription for chronic noncancer pain patients without special
approval
Involved with changing state guidelines or state insurance pharmacy policies
Involved with implementation of new guidelines/policies
Require pain clinics to be regularly certified by state medical board
Involved with changing law/regulations, policy, or medical board requirement
Involved with implementation of new requirement
Require pain clinics to be owned and operated by licensed physicians
Involved with changing law/regulations, policy, or medical board requirement
Involved with implementation of new requirement
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Other changes to laws or policies
Describe any other regulations or laws related to SPF-Rx that you worked on in the past
year. (3,000-character limit) __________________________________________________
Involved with changing law/policy
Involved with implementation
87.1. Did you work with individual organizations (e.g., local hospitals, local primary care
organizations, pharmacies, insurers) to help them to develop or implement organizational
policies related to SPF-Rx goals? E
Yes
No (If selected, you will skip Questions 87.2 and 88)
87.2. Please check the boxes below to indicate any SPF-Rx program activities in this reporting
period related to helping institutions develop or implement organizational policies. (Select all
that apply.)E
PDMP data organizational policy
Worked with medical organizations to incorporate or implement policies to register health
care providers/prescribers with the PDMP
Worked with medical organizations to incorporate or implement policies requiring their
medical providers to query their patients’ PDMP records before prescribing opioids
Worked with pharmacy organizations to incorporate or implement policies to improve
timeliness of PDMP upload
Worked with organizations to incorporate or implement policies to improve scope or quality
of PDMP data
Worked with organizations to establish policies or agreements related to linkage of patient
PDMP records with patient electronic health records (EHRs)
Worked with organizations to establish or implement policies or agreements related to
linkage of PDMP data with vital records (deaths) or overdose data (e.g., emergency room
visits or hospital admissions)
Worked with organizations to incorporate or implement policies to increase PDMP access or
ease of use
Safe prescribing organizational policy
Helped institutions implement/incorporate national CDC (or similar state) prescribing
guidelines into their rules and codes
Helped medical or pharmacy schools to incorporate prescription drug/opioid misuse
prevention-related education into their curricula
Pharmacy organizational policy
Helped organizations with pharmacy benefit strategy change (e.g., institute drug utilization
reviews for high-dose opioids)
Helped pharmacies with policies related to querying PDMP for risky prescription patterns
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Social access organizational policy
Helped with organizational policies related to social access, including safe storage and
disposal of prescription drugs (e.g., help develop policies to facilitate broader distribution of
home lock boxes to individuals filling prescriptions for opioids/controlled substances)
(Describe.) _______________________________________________________________
Development of enforcement organizational policy
Collaborated with organizations (e.g., medical regulatory bodies, law enforcement) to
develop enforcement policies related to pain clinics
Collaborated with medical authorities (e.g., medical board/association) to develop policies to
send letters to health care providers with higher-than-usual opioid prescribing rates or risky
prescribing behaviors based on PDMP data
Reduce consequences
Worked to enact policies to reduce the problems/consequences associated with
prescription drug misuse/abuse (e.g., crime, driving under the influence of prescription
drugs/opioids)
Other (Describe.) __________________________________________________________
Other (Describe.) __________________________________________________________
Other (Describe.) __________________________________________________________
Other (Describe.) __________________________________________________________
Other Organizational Policy
88.
Describe any other work you did in the past year related to helping individual organizations
develop or implement policies that advance SPF-Rx goals. (3,000-character limit).E
_________________________________________________________________________
89.
Describe any new laws, regulations, policies, or licensing requirements that were enacted,
established, or implemented during the past year related to this particular environmental
strategy.E
(3,000-character limit.) ______________________________________________________
III.
Enforcement implementation
This section relates to the implementation of enforcement activities. (Development of new
enforcement-related policies should be reported in the policy section.) 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.
90.1. Did your environmental strategy include enforcement implementation efforts (e.g.,
collaboration with law enforcement or medical/pharmaceutical authorities to respond to
possible prescription drug diversion)? (Select one response.)E
Yes
No (If selected, you will skip Questions 90.2 through 91.2.)
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90.2. Indicate which of the following activities you worked to implement during the past year related
to enforcement.E
Collaborated with organizations (e.g., pharmacies, law enforcement) to prevent or respond
to suspected diversion
Collaborated with organizations to enforce policies, laws, or regulations related to pain
clinics
Collaborated with organizations to enforce policies or guidelines related to opioid prescribing
Collaborated with organizations to send letters or reports to health care providers with
higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP
data
Other major enforcement-related practices or activities in the past year (Describe;
3,000-character limit.) _______________________________________________________
91.1. For this environmental strategy of enforcement, did you collaborate with law enforcement
(e.g., work with law enforcement to familiarize them with high-risk areas of the community)
during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 91.2.)
91.2. How many different law enforcement agencies were engaged in collaboration during the past
year for enforcement? This response should be written as a whole number (e.g., 4).E
_________ law enforcement agencies engaged
IV.
Other environmental interventions
92.1. During the past year, did you work on any environmental strategies related to safe disposal of
prescription drugs, specifically, installing prescription drug drop boxes in pharmacies or law
enforcement agencies or supporting take-back events? E
Yes
No (If selected, you will skip Questions 92.2, 92.3, and 92.4.)
92.2. How many prescription drop boxes were already in your target geographic area before you
began implementing SPF-Rx)? B __________
92.3. During the past year, how many prescription drug boxes did you install? Enter total for each
type of location.E
_________ installed in law enforcement agencies
_________ installed in pharmacies
_________ installed other locations
92.4. How many prescription drug take-back events did you organize or participate in?E _________
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93.
During the past year, did you engage in any activities to increase the distribution or access to
home lock boxes for prescription drugs? E
Yes (Describe; 3,000-character limit.) ____________________________________
No
94.
During the past year, did you engage in any other environmental strategies that did not fall
into the categories of policy, enforcement, or training of environmental influencers? Describe
any other environmental strategy you worked to or did implement during the past year.E
Yes (Describe; 3,000-character limit.)___________________________________________
No
95.1. For your “other environmental interventions,” (Question 92 or Question 94) did you
collaborate with law enforcement? (Select one response.)E
Yes
No (If selected, you will skip Question 95.2.)
95.2. How many different law enforcement agencies were engaged in collaboration during the past
year? This response should be written as a whole number (e.g., 4).E
_________ law enforcement agencies engaged
96.
As part of your environmental strategy, did you work to implement any other enforcement
practices or conduct other activities to affect the implementation of enforcement activities
during the past year? (Select one response.)E
Yes (Describe; 3,000-character limit.)___________________________________________
No
Overall target population reach by this intervention-service type
The questions in this section collect information on the individuals ultimately reached or affected
through your training of environmental influencers, enforcement efforts, policy-related activities, or
other environmental strategies. This goes beyond the number of individuals directly involved in the
training, policy change, or enforcement to estimate the numbers affected in the targeted population
in your entire community. This set of questions specifically refers to [NAME OF INTERVENTIONSERVICE TYPE ACTIVITY].
97.
Estimate the total number of individuals who were reached or affected by your environmental
strategy during the past year. 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.)
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98.
Of the total number of participants reached by your environmental strategy during the past
year (reported in Question 97), 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 97. This response should be written as a whole number (e.g., 4) and not
as a percentage.E
98.1. Females: _____________
98.2. Males: ______________
98.3. Transgender: __________________
98.4
Other: _________________________ (Specify: ____________________________)
98.5. Gender unknown: _______________
99.
Of the total number of participants reached by your environmental strategy during the past
year (reported in Question 97), 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 97. This response should be written as a whole
number (e.g., 4) and not as a percentage.E
99.1
Children age 0 to11: _____________
99.2
Youth age 12 to 17: _____________
99.3. Young adults age 18 to 25: _____________
99.4. Adults age 26 and older: _____________
99.5. Age unknown: ______________
100.
Of the total number of participants reached by your environmental strategy during the past
year (reported in Question 97), 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 reached 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 97. This response should be written as a whole number
(e.g., 4) and not as a percentage.E
100.1. American Indian or Alaska Native: _____________
100.2. Black or African American: _____________
100.3. White: _____________
100.4. Asian: _____________
100.5. Native Hawaiian or Other Pacific Islander: ______________
100.6. Multiracial: ___________
100.7. Other: _____________
100.8. Race unknown: ___________
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101.
Of the total number of participants reached by your environmental strategy during the past
year (reported in Question 97), 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 97. This response should be
written as a whole number (e.g., 4) and not as a percentage.E
101.1. Hispanic, Latino/a, or of Spanish origin: ____________
101.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
101.3. Hispanic ethnicity unknown: ____________
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Information Dissemination Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
102.
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 prescription drug misuse prevention problems in the community
To gain support from the community for prescription drug misuse prevention efforts
To provide information on community norms related to prescription drug misuse
To provide information on the dangers of sharing medications and misusing prescription
drugs
To provide prescription drug misuse prevention information (e.g., information on securing
prescription drugs in the household, information on resisting offers for sharing
prescription/pharmaceutical drugs)
To change individual behaviors with regard to prescription drug misuse
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 prescription drug diversion)
To provide a directory of community resources for prevention of prescription drug misuse
and abuse
Other (Describe.) __________________________________________________________
103.
For this intervention-service type activity, indicate the community members and groups (i.e.,
target audience) to whom you are disseminating the information. (Select all that apply.)E
Health care providers/medical community
Pharmacists/pharmacy community
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
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Law enforcement agencies (e.g., local, tribal, state, and Federal law enforcement agencies,
including the police, the Federal Bureau of Investigation [FBI], and the Drug Enforcement
Administration [DEA],
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)
State, tribal, or local jails and prisons
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.) __________________________________________________________
104.
For this intervention-service type activity, indicate the total number of different community
groups or organizations to whom you disseminated information during the past year, if any.
This response should be written as a whole number (e.g., 4).E
_________ community groups or organizations (If none, enter “0.”)
105.
For this intervention-service type activity, did you engage in a social marketing or social
norms campaign during the past year? 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
106.
Indicate the type(s) of individuals targeted by this information dissemination service type
activity during the past Federal fiscal year.E (autofill after first completed)
106.1. Age group(s) targeted by information dissemination service type activity during the past
Federal fiscal year: (Select all that apply.) E
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.) ___________________________________________________
106.2. Population type(s) targeted by this information dissemination service type activity
during the past Federal fiscal year: (Select all that apply.) E
Middle school students
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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.) ___________________________________________________
107.1. For this particular information dissemination service type activity, did you create or air
television ads during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 107.2 through 107.5.)
107.2. How many individual times did the television ads air during the past year? 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
107.3. How many weeks did the television ads air during the past year? 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
107.4. How many different televisions stations aired the ads air during the past year? 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
107.5. Provide any information you have on the reach of the television ads aired during the past
year. 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.) ______________________________________________
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108.1. For this particular information dissemination service type activity, did you create or air radio
ads during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 108.2 through 108.5.)
108.2. How many individual times did the radio ads air during the past year? 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
108.3. How many weeks did the radio ads air during the past year? 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
108.4. How many different radio stations aired the ads air during the past year? 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
108.5. Provide any information you have on the reach of the radio ads aired during the past year.
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.) ______________________________________________
109.1. For this particular information dissemination service type activity, did you create or publish
print ads during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 109.2 through 109.4.)
109.2. How many individual times did the print ads run during the past year? (Select one
response.)E
_________ Times
109.3. How many different newspapers or magazines displayed the ads during the past year? 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
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109.4. Provide any information you have on the reach of the print ads run during the past year. 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.) ______________________________________________
110.
For this particular information dissemination service type activity, how many special events
(e.g., alcohol-free concerts; invited speakers) were hosted during the past year? This
response should be written as a whole number (e.g., 4).E
_________ special events
111.
For this particular information dissemination service type activity, how many other promotional
activities (e.g., distributing prescription drug take-back information at a health fair) were
implemented during the past year? This response should be written as a whole number
(e.g., 4).E
_________ promotional activities
112.1. For this particular information dissemination service type activity, did you present at
community meetings (e.g., parent-teacher association [PTA] meetings, town hall meetings,
school assemblies) during the past year? 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 skip Questions 112.2 and 112.3.)
112.2. How many community meetings did you present at during the past year? This response
should be written as a whole number (e.g., 4).E
_________ meetings
112.3. What was the total number of participants at all community meetings where you presented
during the past year? This response should be written as a whole number (e.g., 4).E
_________ participants
113.1. For this particular information dissemination service type activity, did you send letters to the
editor of the local newspaper or community newsletters during the past year? (Select one
response.)E
Yes
No (If selected, you will skip Question 113.2.)
113.2. How many letters were published during the past year? This response should be written as
a whole number (e.g., 4).E
_________ letters
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114.1. For this particular information dissemination service type activity, did you produce or distribute
prescription drug misuse prevention posters during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 114.2.)
114.2. How many posters were distributed during the past year? This response should be written as
a whole number (e.g., 4).E
_________ posters
115.1. For this particular information dissemination service type activity, did you produce or distribute
prescription drug misuse prevention brochures during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 115.2.)
115.2. How many brochures were distributed during the past year? This response should be written
as a whole number (e.g., 50).E
_________ brochures
116.1. For this particular information dissemination service type activity, did you provide a related
information line or hotline in the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 116.2.)
116.2. How many individuals called into the information line or hotline in the past year? This
response should be written as a whole number (e.g., 50).E
_________ individuals
117.
For this particular information dissemination service type activity, did you develop or run a
prescription drug misuse prevention-focused clearinghouse or information resource center in
the past year? (Select one response.) E
Yes
No
118.1. For this particular information dissemination service type activity, did you launch or continue
prescription drug misuse prevention-focused Web sites or Facebook pages during the past
year? (Select one response.)E
Yes
No (If selected, you will skip Questions 118.2 through 118.5.)
118.2. What is the number of visitor sessions (visits) that the Web sites had during the past year?
This response should be written as a whole number (e.g., 4).E
Specify number of visits _____
Do not know
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118.3. How many new (compared with returning) visitors did the Web sites have during the past
year? This response should be written as a whole number (e.g., 4).E
Specify number of new visitors _____
Do not know
118.4. What is the total number of unique page views that the Web sites had during the past year?
This response should be written as a whole number (e.g., 4).E
Specify number of unique page views _______
Do not know
118.5. What was the average amount of time spent on the Web sites during the past year? 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
119.
For this particular information dissemination service type activity, did you conduct other
communication activities during the past year? E
Yes (Describe; 3,000-character limit.) __________________________________________
No
The questions in this section collect information on the individuals reached through this information
dissemination service type activity.
120.
Estimate the total number of individuals who were reached or affected by this information
dissemination service type activities for during the past year. 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.)
121.
Of the total number of participants reached by this information dissemination service type
activities during the past year (reported in Question 120), 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 120. This response should be written as a whole
number (e.g., 4) and not as a percentage.E
121.1. Females: _____________
121.2. Males: ______________
121.3. Transgender: ____________________
121.4. Other: __________________________ (Specify: _____________________________)
121.5. Gender unknown: _______________
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122.
Of the total number of participants reached by this information dissemination service type
activities during the past year (reported in Question 120), 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 120. This
response should be written as a whole number (e.g., 4) and not as a percentage.E
122.1. Children age 0 to 11: _____________
122.2. Youth age 12 to 17: _____________
122.3 Young adults age 18 to 25: _____________
122.4 Adults age 26 and older: _____________
122.5. Age unknown: ______________
123.
Of the total number of participants reached by this information dissemination service type
activities during the past year (reported in Question 120), 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 reached 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 120. This response should be
written as a whole number (e.g., 4) and not as a percentage.E
123.1. American Indian or Alaska Native: _____________
123.2. Black or African American: _____________
123.3. White: _____________
123.4. Asian: _____________
123.5. Native Hawaiian or Other Pacific Islander: ______________
123.6. Multiracial: ___________
123.7. Other: _____________
123.8. Race unknown: ___________
124.
Of the total number of participants reached by this information dissemination service type
activities during the past year (reported in Question 120), indicate how many were
Hispanic/Latino and how many were non-Hispanic/Latino. The number of NonHispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants
reported in Question 120. This response should be written as a whole number (e.g., 4) and
not as a percentage.E
124.1. Hispanic, Latino/a, or of Spanish origin: ____________
124.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
124.3. Hispanic ethnicity unknown: ____________
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Section 2D. Monitoring and Evaluation (Subrecipients only)
This section collects information on how you used your monitoring and evaluation findings.
125.1. Have you made changes to your prevention strategies or the implementation of your
prevention interventions during the past Federal fiscal year as the result of the analysis of
your monitoring and evaluation data? (Select one response.)E
Yes
No (If selected, you will skip Question 125.2)
Data not yet collected or analyzed (If selected, you will skip Question 125.2)
Not applicable (If selected, you will skip Question 125.2)
125.2. How did you change your strategy, or which prevention intervention(s) did you modify during
the past Federal fiscal year as the result of the analysis of your monitoring and evaluation
data? E
Changed strategy (Describe.) ___________________________________________
Changed intervention (Select all that apply.):
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
126.
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 effect of your interventions on your targeted consumption,
consequence, or intervening variables. (Select all that apply.) E
Process
evaluation
Outcome
evaluation
126.1. Develop or substantially revise an evaluation plan
126.2. Collect data
126.3. Analyze data
126.4. Produce an evaluation report
126.5. Not applicable
Evaluation activity
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Section 3: Implementation Barriers and Contextual Factors (Both grantees
and subrecipients complete)
In this section, we would like to learn about possible barriers and challenges that had an impact on
implementation or outcomes related to your SPF-Rx prevention activities in your community, state,
tribal area, or jurisdiction during this reporting period. How much impact did the following factors
have on the progress or results of your SPF-Rx efforts in the past Federal fiscal year? (Select one
level of impact for each factor.)
No
impact
Low
impact
Moderate
impact
High
impact
127.1. Limited legal policies/laws or enforcement
127.2. Problems with quality of PDMP data (e.g., data
cleaning, type of information available etc.)
127.3. Problems accessing PDMP data (or with
frequency of access)
127.4 Problems analyzing PDMP data
127.5. Lack of ease of PDMP use for health care
providers
127.6. Problems accessing hospital data to measure
overdoses
127.7. Challenges getting buy-in and support from health
care professionals
127.8. Challenges getting health care providers to
complete PDMP training
127.9. Challenges getting health care providers to
complete safe opioid prescribing training
127.10. Lack of leadership support from medical board or
association
127.11. Lack of understanding by medical community
about addiction
127.12. Lack of leadership support from pharmacy board
or association
127.13. Challenges aligning priorities across public
agencies
127.14. Lack of state leadership to prioritize prescription
drug/opioid misuse prevention (e.g., governor’s
office, legislature)
127.15. Challenges coordinating efforts across agencies
127.16. Challenges collaborating between public health
and substance abuse agencies
127.17. Challenges for substance abuse/mental health
agencies to focus on prevention, given demands
for treatment
127.18. Challenges trying to cover geographic areas that
are too broad
127.19. Lack of relevant prevention interventions for
specific populations at risk
127. Implementation
Barriers E
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
127.20. Not enough funds for prevention efforts for
prescription drug/opioid misuse and abuse
127.21. Cost of prescription drug home lock boxes
127.22. Lack of resources to pay for prescription drug
drop boxes in enough pharmacies or police
stations
127.23. Problems with disposal of returned prescription
drugs
127.24. Lack of transportation of community members to
attend interventions (e.g., parents and youth)
127.25. Cultural barriers
127.26. Language barriers
127.27. Other (Describe.) ___________________
127.28. Other (Describe.) ___________________
127.29. Other (Describe.) ___________________
127.30. Other (Describe.) ___________________
128. To what extent do you think the following contextual factors affected SPF-Rx-related
implementation or outcomes in your community, state, tribal area, or jurisdiction during the past
Federal fiscal year? (Select one level of impact for each factor.) B, F
[Baseline and final only]
No
impact
Low
impact
Moderate
impact
High
impact
128.1. Lack of available mental health treatment (i.e.,
leading to self-medicating)
128.2. Lack of available substance abuse treatment
128.3. Lack of access to medical care and better
treatment options for chronic medical conditions,
including pain
128.4. Lack of community awareness of the risk factors,
extent, or consequences of prescription
drug/opioid misuse
128.5. Easy access to prescription drugs for nonmedical
use
128.6. Lack of trust in government agencies (i.e., public
health authorities, social services, or law
enforcement)
128.7. High poverty rates/low socioeconomic status
128.8. High unemployment, underemployment, or
economic dislocation
128.9. Low literacy or low education levels
128.10. Community social disorganization
128.11. Social isolation
128.12. Lack of opportunities for area youth
128. Broader Contextual Factors B,F
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128.13. Cultural norms, attitudes, or practices favoring
substance use
128.14. Cultural norms, attitudes, or practices that are
resistant to identifying and serving drugdependent individuals
128.15. Stigmatization of drug-dependent individuals in
the community
128.16. Stressful events affecting large portions of the
target population (e.g., natural disasters or other
unexpected traumatic community events)
(Describe.) _________________
128.17. Other (Describe.) __________________
_________________________________
128.18. Other (Describe.) __________________
_________________________________
128.19. Other (Describe.) __________________
_________________________________
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SPF-Rx Cross-Site Evaluation, Annual Implementation Instrument
Section 4: Closing Questions (Both grantees and subrecipients complete)
129.
Provide any additional comments about your SPF-Rx-related prevention intervention activities
here. (Describe; 3,000-character limit.) E
_________________________________________________________________________
130.
Do you have any additional comments about any aspects of the SPF-Rx Initiative? (Describe;
3,000-character limit.) E
_________________________________________________________________________
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| File Type | application/pdf |
| File Title | CLI Part 1 Revision |
| Author | DACCC |
| File Modified | 2017-06-16 |
| File Created | 2017-06-16 |