Form State Director Bas State Director Bas State Director Baseline Survey

OMB # Form Approved

OMB OMB No. 0930-####

Expiration Date: ##/##/##

Opioid State Targeted Response (STR) Evaluation

State/Territory STR Director Baseline Survey

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0xxx. Public reporting burden for this collection of information is estimated to average four (4) hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Information and Directions

The purpose of this evaluation is to collect important grantee-level information about the implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) Opioid State Targeted Response (STR) grant. Survey questions focus on opioid use disorder* services and activities in your state/territory before receiving Opioid STR funding, and planned services and activities to address opioid use disorder using Opioid STR funds. Survey results will be aggregated to protect anonymity. It will take approximately four (4) hours to complete this survey, including the time for reviewing instructions, searching existing data sources, gathering the data needed to answer questions, and answering the questions. The survey does not need to be completed in one sitting, and will automatically save your answers as you enter them.

*Except where noted, all questions in this survey refer to prevention strategies, treatment and/or recovery services for opioid use disorder and related conditions (e.g., non-medical use of prescription pain medication, heroin users, one-time users, overdose) in your state/territory one year before receiving Opioid STR funding. For the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) definition of opioid use disorder, please refer to the attached glossary.

Helpful Materials

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

• Funding and budget information;

• Intervention implementation materials (curricula, programs, etc.);

• Evaluation findings and reports; and

• Organizational policies.

Background Information

Please provide your contact information and information about your current position and role on the Opioid STR grant below.

1.

Name
Work Street Address
Work Street Address
Work City, State, Zip
Work Phone
Work Email

2.

3.

	What is your current employment position?

4.

How long have you been in this position?
1	Years
2	Months

	What is your role in the Opioid STR grant?

Needs & Resources

This section focuses on your state/territory’s needs related to addressing opioid use disorder, and the resources available to your state/territory to address opioid use disorder as of May 1, 2017.

5.

Describe the geographic areas/locations in your state/territory where opioid use disorders were most prevalent as of May 1, 2017. Provide the data source used to make this determination.

	Geographic Areas/Locations	Data Source
a.
b.
c.
d.
e.

6.

Describe the geographic areas/locations in your state/territory where opioid-related deaths were the highest as of May 1, 2017. Provide the data source used to make this determination.

	Geographic Areas/Locations	Data Source
a.
b.
c.
d.
e.

7.

Did your state/territory receive any funding that you used for opioid use disorder prevention strategies, treatment, and/or recovery services (including any federal, state, local, foundation, or private funding) between May 1, 2016 and April 30, 2017?
1	Yes GO TO QUESTION 8
0	No GO TO QUESTION 9

8.

In the table below, indicate whether your state/territory used each funding source for opioid use disorder prevention strategies, treatment, and/or recovery services between May 1, 2016 and April 30, 2017. Where possible, estimate the amount of funding your state/territory has received and used for opioid use disorder prevention strategies, treatment, and/or recovery services between May 1, 2016 and April 30, 2017. (If grant program spans two fiscal years, please include funding received and used during both fiscal years.)

	Funding Source	Check if funding received	Total amount received		Total amount used for opioid prevention strategies		Total amount used for opioid treatment, and/or recovery services
a.	SPF-Partnerships for Success (PFS) (SAMHSA)
b.	Substance Abuse Prevention and Treatment Block Grant (SAMHSA)
c.	SAMHSA Prescription Drug Overdose
d.	SAMHSA Medical-Assisted Treatment (MAT)
e.	CDC Prevention for States (PfS)
f.	CDC PDO Data-Driven Prevention Initiative (DDPI)
g.	SAMHSA Minority HIV/AIDS Initiative
h.	HRSA Rural Opioid Overdose Reversal (ROOR)
i.	Drug-Free Communities (DFC) grant
j.	Other Federal funds (Specify)
k.	Other state/tribal/jurisdiction funds (Specify)
l.	Other local government funds (Specify)
m.	Foundations/nonprofit organizations
n.	Corporate/business entities
o.	Individual donations/funding from fundraising events
p.	Other funding source (Specify)

10.

	Approximately how many state-sponsored trainings on opioid use disorder prevention strategies, treatment, and recovery services were delivered in your state from May 1, 2016 to April 30, 2017? This may include trainings conducted using funding received through state, federal, or other sources (e.g., state general funds, SAMHSA block grants, and others).
	Training Topic			Number of trainings
a.	Prevention of Opioid Use Disorders
b.	Treatment and/or Recovery Services for Opioid Use Disorders
c.	Both (Prevention and Treatment and/or Recovery Services for Opioid Use Disorders)

9.

In the table below, indicate the total number of practitioners/staff in your state/territory’s behavioral health care workforce that provide prevention strategies, treatment, and/or recovery services for opioid use disorders as of May 1, 2017. Provide the data source(s) used to make this determination.

			For opioid use disorders, total number of practitioners/staff providing prevention strategies, treatment and/or recovery services		Data Sources
a.	Physicians (excluding Psychiatrists)
b.	Psychiatrists
c.	Nurse Practitioners
d.	Psychologists
e.	Counselors
f.	Social Workers
g.	Paid Peer Specialists
h.	Volunteer Peer Specialists
i.	Others (Specify)
j.	Total

11.

In the list below, identify A) if the following activities or programs were present in your state/territory as of May 1, 2017, and B) whether your state/territory plans to expand/enhance/develop (or pass new legislation for) any of these activities or programs to address the opioid use disorders in your state.

		A		B
		SELECT ONE		SELECT ALL THAT APPLY
		YES	NO	PLANS TO EXPAND, ENHANCE, OR DEVELOP/ PASS USING OPIOID STR FUNDING	PLANS TO EXPAND, ENHANCE, OR DEVELOP/ PASS NOT USING OPIOID STR FUNDING	NO PLANS TO EXPAND, ENHANCE OR DEVELOP/PASS
a.	Alcohol/Drug Testing Programs	1	0	1	2	0
b.	Alcohol/Drug-free Support Centers (e.g., clubhouses, drop in centers)	1	0	2	3	0
c.	Drug Take-Back Program	1	0	2	3	0
d.	Good Samaritan Law	1	0	2	3	0
e.	Governor’s Cabinet-Level Opioid Council/Team	1	0	2	3	0
f.	Integrated Community Care Models	1	0	2	3	0
g.	MAT Collaboratives	1	0	2	3	0
h.	Naloxone Access Laws	1	0	2	3	0
i.	Naloxone Distribution	1	0	2	3	0
j.	Opioid Prescribing Guidelines	1	0	2	3	0
k.	Opioid-Specific Community Trainings (e.g., first responders)	1	0	2	3	0
l.	Pain Management Services	1	0	2	3	0
m.	“Pill Mill” Laws	1	0	2	3	0
n.	Prescription Drug Monitoring Program	1	0	2	3	0
o.	Public Information Campaigns	1	0	2	3	0
p.	Substance Abuse Education	1	0	2	3	0
q.	Syringe Services Including Distribution Sites	1	0	2	3	0
r.	Telehealth	1	0	2	3	0
s.	Other (Specify)	1	0	2	3	0

Data Use

This section focuses on data sources available to your state/territory and data management strategies used to address opioid use disorders before receiving Opioid STR funding.

12.

In the table below, list all sources of state/territory-level data relevant to opioid use disorder that your state/territory has used to monitor opioid use disorder as of May 1, 2017. (Possible data sources include the Youth Risk Behavior Surveillance System (YRBSS), the Behavioral Risk Factor Surveillance System (BRFSS), other statewide school or adult state surveys, arrest data, and emergency room overdose data).

	Data Source	Frequency of data collection SELECT ONE ONLY	Most recent data collection time point (Year)	Geographic level of data availability SELECT ALL THAT APPLY	Subgroup level of data availability SELECT ALL THAT APPLY	Respondents/ population SELECT ALL THAT APPLY
a.		1 Semi-annual 2 Annual 3 Every 2 years 4 Other (Specify)		1 State 2 Tribal entity 3 Jurisdiction 4 Region 5 County 6 School 7 Other (Specify)	1 Race 2 Ethnicity 3 Gender 4 Age 5 Other (Specify)	1 Adolescents 2 Adults 3 Other (Specify)
b.		1 Semi-annual 2 Annual 3 Every 2 years 4 Other (Specify)		1 State 2 Tribal entity 3 Jurisdiction 4 Region 5 County 6 School 7 Other (Specify)	1 Race 2 Ethnicity 3 Gender 4 Age 5 Other (Specify)	1 Adolescents 2 Adults 3 Other (Specify)
c.		1 Semi-annual 2 Annual 3 Every 2 years 4 Other (Specify)		1 State 2 Tribal entity 3 Jurisdiction 4 Region 5 County 6 School 7 Other (Specify)	1 Race 2 Ethnicity 3 Gender 4 Age 5 Other (Specify)	1 Adolescents 2 Adults 3 Other (Specify)
d.		1 Semi-annual 2 Annual 3 Every 2 years 4 Other (Specify)		1 State 2 Tribal entity 3 Jurisdiction 4 Region 5 County 6 School 7 Other (Specify)	1 Race 2 Ethnicity 3 Gender 4 Age 5 Other (Specify)	1 Adolescents 2 Adults 3 Other (Specify)

13.

Between May 1, 2016 and April 30, 2017, did your state/territory collect information on how it implements prevention strategies that address opioid use disorders (e.g., what prevention approaches are implemented, who implements them, what population(s) and/or geographic areas are targeted, how many dollars are spent, who monitors reach and/or impact)?
1	Yes
0	No

14.

Between May 1, 2016 and April 30, 2017, did your state/territory collect information on how it implements treatment and/or recovery services interventions that address opioid use disorders (e.g., what treatment and/or recovery approaches are implemented, who implements them, what population(s) and/or geographic areas are targeted, how many dollars are spent, who monitors reach and/or impact)?
1	Yes
0	No

15.

16.

Between May 1, 2016 and April 30, 2017, did your state/territory integrate opioid use disorder data (such as data that must be reported for the Opioid STR grant) with data from other agencies/groups to address opioid use disorder (e.g., data from pharmacies, poison control, first responders, etc.)?
1	Yes
0	No

Between May 1, 2016 and April 30, 2017, did your state/territory share state/territory-level data with key stakeholders to address opioid use disorders?
1	Yes
0	No

17.

In the table below, indicate whether the following community-level and state-level data elements were available as of May 1, 2017 and, if so, whether your agency had access to these data elements as of May 1, 2017.

		Data Availability						Data Access
		Were data available at the state-level?			Were data available at the community-level?			Did your agency have access to these data at the state-level?			Did your agency have access to these data at the community-level?
		YES	NO	DON’T KNOW	YES	NO	DON’T KNOW	YES	NO	DON’T KNOW	YES	NO	DON’T KNOW
a.	Rates of prescription drug misuse in the past 30 days	1	0	d	1	0	d	1	0	d	1	0	d
b.	Rates of lifetime prescription drug misuse (ever misused)	1	0	d	1	0	d	1	0	d	1	0	d
c.	Rates of high dose opioid prescribing (e.g., >90MME/day)	1	0	d	1	0	d	1	0	d	1	0	d
d.	Rates of opioid and benzodiazepine co-prescribing	1	0	d	1	0	d	1	0	d	1	0	d
e.	Rates of multiple prescriber episodes for opioid pain medication (as indicator of possible “doctor shopping”)	1	0	d	1	0	d	1	0	d	1	0	d
f.	Rates of multiple pharmacy episodes for opioid pain medication	1	0	d	1	0	d	1	0	d	1	0	d

CON’T

17.

In the table below, indicate whether the following community-level and state-level data elements were available as of May 1, 2017 and, if so, whether your agency had access to these data elements as of May 1, 2017.

		Data Availability						Data Access
		Were data available at the state-level?			Were data available at the community-level?			Did your agency have access to these data at the state-level?			Did your agency have access to these data at the community-level?
		YES	NO	DON’T KNOW	YES	NO	DON’T KNOW	YES	NO	DON’T KNOW	YES	NO	DON’T KNOW
g.	Mortality rates due to prescription drug/opioid overdose	1	0	d	1	0	d	1	0	d	1	0	d
h.	Emergency room visits/hospital admissions related to prescription drug/opioid use disorder	1	0	d	1	0	d	1	0	d	1	0	d
i.	Calls to poison center related to prescription drug/opioid use disorder	1	0	d	1	0	d	1	0	d	1	0	d
j.	Local data on geographic patterns of opioid overdoses	1	0	d	1	0	d	1	0	d	1	0	d
k.	Other (specify)	1	0	d	1	0	d	1	0	d	1	0	d

Prescription Drug Monitoring Program (PDMP) Data

18.

19.

GO TO QUESTION 22

As of May 1, 2017, did your state/territory have an active Prescription Drug Monitoring Program (PDMP)?
1	Yes
0	No
d	Don’t know

GO TO QUESTION 22

20.

As of May 1, 2017, did your state/territory have access to the PDMP to extract and use data?
1	Yes
0	No
d	Don’t know

Did your state/territory use PDMP data for the following purposes between May 1, 2016 and April 30, 2017?

		MARK ONE FOR EACH ROW
		YES	NO
a.	Help select and implement strategies and services to address opioid use disorders	1	0
b.	Help make decisions about selecting providers and organizations that receive Opioid STR funding (that is, Opioid STR sub-recipients)	1	0
c.	Extract and report rates of physician registration with prescription drug monitoring program	1	0
d.	Extract and report use of PDMP by physicians (number of queries; percentage of physicians making queries)	1	0
e.	Extract and report opioid prescribing rates	1	0

ASK ONLY IF Q18 AND Q19 ARE “YES”

21.

Which PDMP data management and data use activity or activities has your state/territory completed between May 1, 2016 and April 30, 2017? SELECT ALL THAT APPLY
1	Increased access to PDMP data at the grantee/state/territory level
2	Increased access to PDMP data at the sub-recipient level
3	Increased usage of PDMP data at the grantee/state/territory level
4	Increased usage of PDMP data at the sub-recipient level
5	Increased the quality of PDMP data collected
6	Increased registration for the PDMP
7	Increased voluntary PDMP enrollment
8	Increased mandatory PDMP enrollment
9	Increased timely data upload by pharmacists to the PDMP
10	Integrated PDMPs with electronic health records
11	Integrated PDMPs with health information exchanges
12	Integrated PDMP data with vital records (e.g., deaths)
13	Increased reports to prescribers
14	Increased reports to dispensers
15	Increased reports to licensing boards
16	Any other efforts to improve data infrastructure (Specify)

Infrastructure

One of the goals of the Opioid STR program is to understand and support the infrastructure at the state/territory and community levels needed to address opioid use disorder. This section focuses on ways in which grantees and sub-recipients (communities/programs) used and leveraged structures, processes, and policies to address opioid use disorder in their state before receiving Opioid STR funding.

22.

Which of the following guidelines and regulations existed in your state/territory as of May 1, 2017? SELECT ALL THAT APPLY
1	Required universal registration with the Prescription Drug Monitoring Program (PDMP)
2	Doctors can assign authorized delegates to access the PDMP
3	Requirements for prescribers to query PDMP before prescribing opioids in certain conditions (e.g., for more than short-term use)
4	Pharmacists have a set timeframe for uploading opioid dispensing data
5	Using PDMP data for public health surveillance and prevention
6	Inter-state agreements to share PDMP data
7	Requirements for prescribers to receive training on safe opioid prescribing
8	Limit to dose of opioid prescription without special approval
9	Limit to the duration of opioid prescription without special approval
10	Limit to the duration of opioid prescription for non-cancer patients without special approval
11	Requirements to regularly certify pain clinics by the state medical board
12	Requirements that pain clinics must be owned and operated by a licensed physician
13	Other relevant PDMP guidelines or regulations not captured above (Specify)

23.

Did your state/territory have a state-level workgroup to address opioid use disorder that met regularly (e.g., every two weeks, monthly, quarterly) between May 1, 2016 and April 30, 2017?
1	Yes, my state/territory had a workgroup that met regularly
2	Yes, my state/territory had a workgroup, but it did not meet regularly
3	No, my state/territory did not have a workgroup

24.

Did a statewide/territory-wide strategic plan exist to address opioid use disorder, including prevention of overdose and misuse, treatment and recovery services as of May 1, 2017?
1	Yes
0	No

Addressing Opioid Use Disorder

This section focuses on opioid use disorder prevention strategies, treatment, and/or recovery services available in your state/territory before receiving Opioid STR funding.

25.

In the table below, provide the total number of a) people who received opioid use disorder-specific treatment services, and b) people who received opioid use disorder-specific recovery services in your state/territory between May 1, 2016 and April 30, 2017.

		TOTAL
a.	Total number of people who received treatment services between May 1, 2016 and April 30, 2017.
b.	Total number of people who received recovery services between May 1, 2016 and April 30, 2017.

26.

In the table below, to the best of your knowledge, list all of the opioid-specific prevention strategies that your state/territory has delivered between May 1, 2016 and April 30, 2017, the type of prevention strategy delivered, and the total number of people that received each strategy. Primary prevention refers to preventing new cases of opioid use disorder, while secondary prevention refers to identifying and treating opioid use disorder early on.

	Prevention strategy		Type of prevention strategy (Primary or Secondary)		Total number of people that received the strategy (if able to obtain)
a.
b.
c.
d.
e.
f.

28.

27.

In the table below, to the best of your knowledge, list all of the opioid-specific treatment strategies that your state/territory has delivered between May 1, 2016 and April 30, 2017 and the total number of people that received each strategy.

	Treatment strategy			Total number of people that received the strategy (if able to obtain)
a.
b.
c.
d.
e.
f.

In the table below, to the best of your knowledge, list all of the opioid-specific recovery strategies that your state/territory has delivered between May 1, 2016 and April 30, 2017 and the total number of people that received each strategy.

	Recovery strategy			Total number of people that received the strategy (if able to obtain)
a.
b.
c.
d.
e.
f.

Plans to Address Opioid Use Disorder Using Opioid STR Funds

This section focuses on plans to provide opioid use disorder prevention strategies, treatment, and/or recovery services in your state/territory using Opioid STR funding.

29.

In the list below, identify the opioid use disorder treatment and/or recovery services that your state/territory: (1) has not implemented as of May 1, 2017 and does not plan to develop using Opioid STR funding; (2) has not implemented as of May 1, 2017 and plans to develop using Opioid STR funding, (3) has already implemented and plans to expand using Opioid STR funding; or (4) has already implemented and does not plan to expand using Opioid STR funding. Where possible, estimate how your capacity to treat will be improved by specifying the number of expected new cases (i.e., individuals who have not previously received service) you expect to serve with these services using Opioid STR funding. We will use these data to monitor capacity improvements over time.

		MARK ONE FOR EACH ROW
		NOT IMPLEMENTED; NO PLANS TO DEVELOP	NOT IMPLEMENTED, PLANS TO DEVELOP	IMPLEMENTED; PLANS TO EXPAND	IMPLEMENTED, NO PLANS TO EXPAND	# EXPECTED NEW CASES
PREVENTION CONTINUUM OF CARE
a.	Primary or Secondary Prevention (e.g., universal school-based prevention)	1	2	3	4
b.	Outreach, Information, and Referral	1	2	3	4
c.	Screening Brief Intervention and Referral to Treatment (SBIRT)	1	2	3	4
d.	Early Intervention (e.g., .5 ASAM level of care)	1	2	3	4
TREATMENT CONTINUUM OF CARE
e.	Detoxification	1	2	3	4
f.	Outpatient (e.g., treatment that occurs once a week in an outpatient setting)	1	2	3	4
g.	Intensive Outpatient	1	2	3	4
h.	Day Treatment	1	2	3	4
i.	Inpatient/Hospital (Other Than Detox)	1	2	3	4
RECOVERY CONTINUUM OF CARE
j.	Continuing Care (e.g., step-down treatment services	1	2	3	4
k.	Practitioner Recovery Supports	1	2	3	4
l.	Peer Recovery Support Services	1	2	3	4

CON’T

29.

In the list below, identify the opioid use disorder treatment and/or recovery services that your state/territory: (1) has not implemented as of May 1, 2017 and does not plan to develop using Opioid STR funding; (2) has not implemented as of May 1, 2017 and plans to develop using Opioid STR funding, (3) has already implemented and plans to expand using Opioid STR funding; or (4) has already implemented and does not plan to expand using Opioid STR funding. Where possible, estimate how your capacity to treat will be improved by specifying the number of expected new cases (i.e., individuals who have not previously received service) you expect to serve with these services using Opioid STR funding. We will use these data to monitor capacity improvements over time.

		MARK ONE FOR EACH ROW
		NOT IMPLEMENTED; NO PLANS TO DEVELOP	NOT IMPLEMENTED, PLANS TO DEVELOP	IMPLEMENTED; PLANS TO EXPAND	IMPLEMENTED, NO PLANS TO EXPAND	# EXPECTED NEW CASES
SPECIFIC SERVICE COMPONENTS w/in CONTINUUM OF CARE
Pharmacological Interventions
m.	Methadone	1	2	3	4
n.	Buprenorphine	1	2	3	4
o.	Naltrexone (Oral)	1	2	3	4
p.	Naltrexone (Extended-release injectable)	1	2	3	4
Treatment Services
q.	Case Management	1	2	3	4
r.	Co-Occurring Treatment Services (i.e., mental health and substance abuse services)	1	2	3	4
s.	Infectious Disease (e.g., HIV/AIDS, Hepatitis) Services	1	2	3	4
t.	Trauma-focused/informed Services	1	2	3	4
u.	Education/Support Groups (patients/families)	1	2	3	4
v.	Other Enhanced Services That Address Psychosocial Problems Concomitant with the OUD (Specify)	1	2	3	4

CON’T

29.

In the list below, identify the opioid use disorder treatment and/or recovery services that your state/territory: (1) has not implemented as of May 1, 2017 and does not plan to implement using Opioid STR funding; (2) has not implemented as of May 1, 2017 and plans to develop using Opioid STR funding, (3) has already implemented and plans to expand using Opioid STR funding; or (4) has already implemented and does not plan to expand using Opioid STR funding. Where possible, estimate how your capacity to treat will be improved by specifying the number of expected new cases (i.e., individuals who have not previously received service) you expect to serve with these services using Opioid STR funding. We will use these data to monitor capacity improvements over time.

			MARK ONE FOR EACH ROW
		NOT IMPLEMENTED; NO PLANS TO DEVELOP	NOT IMPLEMENTED, PLANS TO DEVELOP	IMPLEMENTED; PLANS TO EXPAND	IMPLEMENTED, NO PLANS TO EXPAND	# EXPECTED NEW CASES
w.	Wrap-Around Services (If possible, provide additional information about specific wrap-around services below in rows x through cc)	1	2	3	4
x.	Child Care	1	2	3	4
y.	Employment Services	1	2	3	4
z.	Housing	1	2	3	4
aa.	Individual Services Coordination	1	2	3	4
bb.	Transportation	1	2	3	4
cc.	Other (specify)	1	2	3	4
INFRASTRUCTURE
dd.	Health Information Technology Systems	1	2	3	4
ee.	Data Extraction for Real Time Reporting	1	2	3	4
ff.	Secured Physical Space (e.g., purchased building)	1	2	3	4
gg.	Opioid-Specific Practitioner Trainings	1	2	3	4
OTHER
hh.	Other (specify)	1	2	3	4

30.

In the table below, indicate the population(s) that your state/territory plans to target for your Opioid STR prevention strategies, treatment, and/or recovery services. For this question, we would like to know if your state/territory plans to target specific groups of people for these treatment and recovery interventions. For example, if you are delivering a treatment intervention designed to target all pregnant women in an area, then you would select only “Females”; you would not have to select all the possible race/ethnicity categories that might be pregnant. If, however, you are delivering a treatment specifically designed to target African American and Hispanic pregnant women, then you would select “Hispanic/Latinos” and “African Americans” as well.

(These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.)

		MARK ONE OR MORE FOR EACH ROW
Check if you will be targeting this population for		Prevention	Treatment	Recovery
a.	A specific population has not been identified to target for Opioid STR activities	1	2	3
b.	Males	1	2	3
c.	Females	1	2	3
d.	Hispanics/Latinos (Including those from Central America, Cuba, Dominican Republic, Mexico, Puerto Rico, and South American countries)	1	2	3
e.	African Americans	1	2	3
f.	Asians (Including those from Southeast Asia, China, the Philippines, Japan, Korea, Vietnam, and other Asian countries)	1	2	3
g.	Native Hawaiians or other Pacific Islanders	1	2	3
h.	Alaska Natives	1	2	3
i.	American Indians	1	2	3
j.	Caucasians	1	2	3
k.	Children (aged <12)	1	2	3
l.	Adolescents (12-17)	1	2	3
m.	Transitional Age Youth (18-25)	1	2	3
n.	Adults (26-64)	1	2	3
o.	Adults (aged 65+)	1	2	3
p.	Parents/caregivers	1	2	3

CON’T

30.

In the table below, indicate the population(s) that your state/territory plans to target for your Opioid STR prevention strategies, treatment, and/or recovery services. For this question, we would like to know if your state/territory plans to target specific groups of people for these treatment and recovery interventions. For example, if you are delivering a treatment intervention designed to target all pregnant women in an area, then you would select only “Females”; you would not have to select all the possible race/ethnicity categories that might be pregnant. If, however, you are delivering a treatment specifically designed to target African American and Hispanic pregnant women, then you would select “Hispanic/Latinos” and “African Americans” as well.

(These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.)

		MARK ONE OR MORE FOR EACH ROW
Check if you will be targeting this population for		Prevention	Treatment	Recovery
q.	Physicians/health care providers/prescribers	1	2	3
r.	Pharmacists/dispensers	1	2	3
s.	Current or former military or military families	1	2	3
t.	Lesbian/gay/bisexual/transgender/questioning (LGBTQ)	1	2	3
u.	People living in poverty	1	2	3
v.	People whose primary language is other than English (or who have limited English proficiency (LEP))	1	2	3
w.	People with mental illness	1	2	3
x.	People with disabilities (e.g., hearing, visually, or physically impaired)	1	2	3
y.	People who are reentering the community	1	2	3
z.	Homeless	1	2	3
aa.	People living with HIV/AIDS	1	2	3
bb.	Injection Drug Users	1	2	3
cc.	Other target population (Specify)	1	2	3
dd.	Other target population (Specify)	1	2	3
ee.	Other target population (Specify)	1	2	3
ff.	Other target population (Specify)	1	2	3
gg.	Will target all populations for Opioid STR activities	1	2	3

31.

How would you describe the community or communities that you plan to target for your Opioid STR treatment and/or recovery services? SELECT ALL THAT APPLY
1	Large urban area (population of more than 500,000)
2	Smaller urban area (population of 50,000 to 500,000)
3	Small town or urban cluster (population or 2,500 to 49,999)
4	Rural
5	Entire state
7	Other (specify)

32.

How would you describe the community or communities that you plan to target for your Opioid STR prevention strategies? SELECT ALL THAT APPLY
1	Large urban area (population of more than 500,000)
2	Smaller urban area (population of 50,000 to 500,000)
3	Small town or urban cluster (population or 2,500 to 49,999)
4	Rural
5	Entire state
6	Other (specify)

33.

How will your state/territory increase access to opioid use disorder prevention strategies, treatment, and/or recovery services using Opioid STR funding for underserved populations (which may include racial/ethnic minority populations, individuals who are difficult to engage in services, or other populations in your state)? SELECT ALL THAT APPLY
1	Complete a Disparities Impact Statement
2	Identify high-needs/low capacity communities
3	Identify populations that experience health disparities
4	Request training/technical assistance (T/TA) about delivering services or strategies to high-needs communities
5	Request training/technical assistance (T/TA) about delivering services or strategies to populations that experience health disparities
6	Monitor and/or evaluate approaches used to address health disparities populations
7	Measure outcomes of health disparities populations
8	Other (specify)

Thank you for your participation!

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Opioid State Targeted Response (STR) Evaluation
Subject	SAQ
Author	MATHEMATICA
File Modified	0000-00-00
File Created	2021-01-22