Form Community-Program Community-Program Community-Program Director Baseline

Form Approved

OMB No. 0930-####

Expiration Date: ##/##/##

Opioid State Targeted Response (STR) Evaluation

Community/Program 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 three (3) 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. Questions in this survey focus on opioid use disorder* services and activities in your community/program 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 three (3) 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 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 community/program 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;

• Client-level service records;

• 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.

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

2.

1.

	What is your current employment position?

3.

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

Needs & Resources

This section focuses on your needs related to addressing opioid use disorder, and the resources available to your community/program to address opioid use disorder before receiving Opioid STR funding.

	Please provide a brief description (1-2 sentences) of the types of services your program provides.

5.

4.

6.

	Please provide a brief description (1-2 sentences) of the individuals your program serves.

Did your community/program receive any funding 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 7
0	No GO TO QUESTION 8

In the table below, indicate whether your community/program 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 community/program 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		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)

7.

In the table below, indicate the total number of practitioners/staff in your community/program that provide prevention strategies, treatment, and/or recovery services for opioid use disorder as of May 1, 2017. Provide the data source(s) used to make this determination.

		For opioid use disorder, 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

8.

In the table below, indicate the total number of providers in your community/program by category who have been trained to implement Medication Assisted Therapy (MAT) and the total number of providers in your community/program that provided MAT services as of May 1, 2017. Provide the data source(s) used to make this determination.

		Total number trained to provide MAT services as of May 1, 2017.		Total number providing MAT services as of May 1, 2017.		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

9.

10. Between March 1, 2016 and March 1, 2017, did your state/territory collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?.

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

		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

11. Between March 1, 2016 and March 1, 2017, did your state/territory collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?.

In the table below, select the area(s) in which your community/program would benefit from training and technical assistance (T/TA) related to evaluating your efforts related to addressing opioid use disorder. We are specifically asking about guidance and T/TA related to evaluation activities that support and/or inform your response to the opioid abuse crisis.

	Evaluation Training/Technical Assistance (T/TA) Areas	Do you need T/TA in this area?
		MARK ONE FOR EACH ROW
		YES	NO
a.	Completing of needs and resource assessment	1	0
b.	Using data for prevention, treatment, and/or recovery assessment, planning, and monitoring	1	0
c.	Using opioid addiction and epidemiology data, including risk and protective factors	1	0
d.	Developing an evaluation plan	1	0
e.	Finding data sources	1	0
f.	Collecting data	1	0
g.	Analyzing data	1	0
h.	Training staff about evaluation activities	1	0
i.	Building collaborative relationships with stakeholders and partner agencies	1	0
j.	Recruiting participants	1	0
k.	Conducting culturally competent evaluation	1	0
l.	Using data to understand and address health disparities	1	0
m.	Identifying evaluation goals and outcomes	1	0
n.	Other (specify)	1	0
o.	Other (specify)	1	0
p.	Other (specify)	1	0

Data Use

This section focuses on data sources available to you and data management strategies used to address opioid use disorder in the year prior to receiving Opioid STR funding.

12. Between March 1, 2016 and March 1, 2017, did your state/territory collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?.

In the table below, list all sources of community/program-level data relevant to opioid use disorder that your community/program 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 March 1, 2016 and March 1, 2017, did your state/territory collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?.

14. Between March 1, 2016 and March 1, 2017, did your state/territory collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?.

Between May 1, 2016 and April 30, 2017, did your community/program collect data on how it implements prevention strategies that address opioid use disorders?
1	Yes
0	No

Between May 1, 2016 and April 30, 2017, did your community/program collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?
1	Yes
0	No

15.etween March 1, 2016 and March 1, 2017, did your state/territory collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?.

Between May 1, 2016 and April 30, 2017, did your community/program 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

16.

Between May 1, 2016 and April 30, 2017, did your community/program share data with key stakeholders to address opioid use disorder?
1	Yes
0	No

In the table below, indicate whether the following community-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.

		Were data available at the community-level?			Did your agency have access to these data at the community-level?
		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
b.	Rates of lifetime prescription drug misuse (ever misused)	1	0	d	1	0	d
c.	Rates of high dose opioid prescribing (e.g., >90MME/day)	1	0	d	1	0	d
d.	Rates of opioid and benzodiazepine co-prescribing	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
f.	Rates of multiple pharmacy episodes for opioid pain medication	1	0	d	1	0	d
g.	Mortality rates due to prescription drug/opioid overdose	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
i.	Calls to poison center related to prescription drug/opioid use disorder	1	0	d	1	0	d
j.	Local data on geographic patterns of opioid overdoses	1	0	d	1	0	d
k.	Other (specify)	1	0	d	1	0	d

17.

GO TO QUESTION 22

18.

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

19.

GO TO QUESTION 22

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

Did your community/program 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 disorder	1	0
b.	Extract and report rates of physician registration with prescription drug monitoring program	1	0
c.	Extract and report use of PDMP by physicians (number of queries; percentage of physicians making queries)	1	0
d.	Extract and report opioid prescribing rates	1	0

20.

ASK ONLY IF Q18 AND Q19 ARE “YES”

21.

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

Addressing Opioid Use Disorder

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

22.

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 community/program 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.

23.

In the table below, to the best of your knowledge, list all of the opioid-specific prevention strategies that your community/program 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.

24.

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

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

25.

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

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

26.

In the table below, provide the total number of people within each demographic group who met DSM criteria for an opioid use disorder in your community/program between May 1, 2016 and April 30, 2017. For the DSM definition of opioid use disorder, please refer to the attached glossary.

AGE

17 and under

18-24

25-44

45-64

65 and over

TOTAL

Pregnant Women

TOTAL

M

F

M

F

M

F

M

F

M

F

M

F

a.

White

b.

Black or African American

c.

Native Hawaiian/ Other Pacific Islander

d.

Asian

e.

American Indian/ Alaskan Native

f.

More Than One Race Reported

g.

Unknown

h.

Not Hispanic or Latino

i.

Hispanic or Latino

27.

In the table below, provide the total number people within each demographic group who have received opioid use disorder treatment from your community/program between May 1, 2016 and April 30, 2017. Please only report the number of people who met DSM criteria for opioid use disorder.

AGE

17 and under

18-24

25-44

45-64

65 and over

TOTAL

Pregnant Women

TOTAL

M

F

M

F

M

F

M

F

M

F

M

F

a.

White

b.

Black or African American

c.

Native Hawaiian/ Other Pacific Islander

d.

Asian

e.

American Indian/ Alaskan Native

f.

More Than One Race Reported

g.

Unknown

h.

Not Hispanic or Latino

i.

Hispanic or Latino

28.

In the table below, provide the total number of those people in the following specific target populations who have received opioid use disorder treatment from your community/program between May 1, 2016 and April 30, 2017. Please only report the number of people who met DSM criteria for opioid use disorder.

	Target Population	TOTAL
a.	Children (< 12)
b.	Adolescents (12-18)
c.	Adults aged 65+
d.	Military/Veterans
e.	LGBTQ
f.	People living in poverty
g.	People whose primary language is not English (LEP population)
h.	People with co-occurring mental illness
i.	Reentry Populations
j.	Homeless
k.	Other (specify)

29.

In the table below, provide the total number of people within each demographic group who received opioid use disorder recovery services from your community/program between May 1, 2016 and April 30, 2017. Please only report the number of people who met DSM criteria for opioid use disorder.

AGE

17 and under

18-24

25-44

45-64

65 and over

TOTAL

Pregnant Women

TOTAL

M

F

M

F

M

F

M

F

M

F

M

F

a.

White

b.

Black or African American

c.

Native Hawaiian/ Other Pacific Islander

d.

Asian

e.

American Indian/ Alaskan Native

f.

More Than One Race Reported

g.

Unknown

h.

Not Hispanic or Latino

i.

Hispanic or Latino

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 community/program using Opioid STR funding.

30.

In the table below, identify the opioid use disorder prevention, treatment, and recovery services that your community/program: (1) had not implemented as of May 1, 2017 and does not plan to develop using Opioid STR funding; (2) had 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

30.

In the table below, identify the opioid use disorder treatment and/or recovery services that your community/program: (1) had not implemented as of May 1, 2017 and does not plan to develop using Opioid STR funding; (2) had 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

30.

In the table below, identify the opioid use disorder treatment and/or recovery services that your community/program: (1) had not implemented as of May 1, 2017 and does not plan to develop using Opioid STR funding; (2) had 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 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

CON’T

31.

In the table below, indicate the population(s) that your community/program plans to target for your Opioid STR prevention strategies, treatment, and/or recovery services. For this question, we would like to know if your community/program 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

31.

In the table below, indicate the population(s) that your community/program plans to target for your Opioid STR prevention strategies, treatment, and/or recovery services. For this question, we would like to know if your community/program 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 are 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

32.

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
6	Other (specify)

33.

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)

34.

How will your community/program 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 Program Director Survey
Subject	SAQ
Author	MATHEMATICA
File Modified	0000-00-00
File Created	2021-01-22