Form Section A: Rx Section A: Rx Section A: Rx

Division of State Programs–Management Reporting Tool
(DSP-MRT)

DSP-MRT Supplement for SPF-Rx Grants

OMB No. 0930-0354

Expiration Date: xx/xx/xxxx

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 0930-0354.  Public reporting burden for this collection of information is estimated to average 1 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 Rm 15E57B, Rockville, Maryland, 20857.

1. Contact Information

GATHERED IN THE GENERAL MONITORING TOOL—NO UNIQUE ITEMS

2. Needs Assessment

   1. Accomplishments and Barriers

GATHERED IN THE GENERAL MONITORING TOOL WITH MOST ITEMS IN THE GENERAL TOOL—HOWEVER USE INSTRUCTIONAL LANGUAGE AND DROPDOWN MENU VARYING BY PROGRAM—THESE ARE NOTED IN THE GENERAL MONITORING TOOL

PARAGRAPH BELOW SHOULD BE INSERTED AS 1^ST PARAGRAPH.

The assessment step involves the systematic gathering and examination of data about prescription drug misuse/abuse and opioid overdose issues, related conditions, and consequences in the area of concern in your community(ies). Assessing the issues means pinpointing where the problems are located in the community and the populations impacted. It also means examining the conditions within the community that put its population at risk for the problems, and identifying conditions that—now or in the future—could protect the population against the problems. Your needs assessment should include an assessment of the current use of you Prescription Drug Monitoring Program (PDMP) in regards to accessing the data, use by targeted communities, and outcomes related to PDMP use.

UNIQUE ITEM FOR SPF-Rx INSERTED AFTER PAGE ID 2.1.1.1 BUT BEFORE PAGE ID 2.1.2

Item	Type of Item/ Response Options	Technical Notes
Have you completed your needs assessment?	Radio buttons: Y/N	[After Page ID 2.1.1.1. and before Page ID 2.1.2] If No, skip remaining items in needs assessment section.
Were PDMP data incorporated into your needs assessment?	Radio buttons: Y/N

2. Needs Assessment Upload

GATHERED IN THE GENERAL MONITORING TOOL

3. Capacity

GATHERED IN THE GENERAL MONITORING TOOL—UNIUE INTRO TEXT FOR 1^ST SENTENCE BELOW. SHOULD BE INSERTED AT BEGINNING OF CAPACITY SECTION, 1^ST PARAGRAPH.

Capacity refers to the various types and levels of resources available to establish and maintain a community overdose prevention system. <ADD REST OF INTRO PARAGRAPH FROM GENERAL MONITORING TOOL>

1. Advisory Council and Epidemiological Outcomes Workgroup (EOW) Membership

UNIQUE ITEM FOR SPF-Rx THAT IS INTENDED TO PULL FROM PFS IF INFORMATION IS AVAILABLE THERE—[PAGE ID AFTER 2.2 BUT BEFORE 2.2.1]

Item	Type of Item/ Response Options	Technical Notes
3.1.1. Is your SPF-Rx grant guided by input from an Advisory Council?	Radio buttons: Y/N	If Yes, ask next question. If No, skip to question 3.1.3.
3.1.2 Does your SPF-Rx grant use the same Advisory Council as was/is used for your PFS grant?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed. If No, ask item 3.1.3. If Yes, information can be reviewed in PFS reports, and skip to Section 3.2.
3.1.3 Is your SPF-Rx grant guided by input from other workgroups such as an EOW?	Radio buttons: Y/N	If Yes, ask next question. If No, skip to Section 3.2.
3.1.4. Does your SPF-Rx grant use the same workgroups as were/are used for your PFS grant?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed. If No, ask next set of items in section. If Yes, information can be reviewed in PFS reports, and skip to Section 3.2.

ADD/EDIT MEMBERSHIP SECTION—UNIQUE ITEM FOR SPF-Rx (PAGE ID 2.2.1.1 ADD BETWEEN ITEMS 4 AND 5)

Item	Type of Item/ Response Options	Technical Notes
Has this member contributed to improving PDMP partnerships at agency or state/tribal levels?	Radio buttons: Y/N	PAGE ID 2.2.1.1 ADD BETWEEN ITEMS 4 AND 5

2. Advisory Council and EOW Meetings

GATHERED IN THE GENERAL MONITORING TOOL

3. Grantee and Other Resources

[This Section is unique to SPF-Rx and would be inserted at the beginning of the current Grants and Other Resources Section on Page ID 2.2.4 in the General Monitoring Tool.]

Use this section to enter information regarding leveraging resources, including state-/grantee-level opioid workgroups and grantee-level funding resources. Note that this section captures information about opioid-specific workgroups outside of your State/Tribal Epidemiological Outcomes Workgroup (SEOW/TEOW). Information about SEOW/TEOW will be reported in a separate section.

Item	Type of Item/ Response Options	Technical Notes
Do you have a state-/grantee-level opioid workgroup?	Radio buttons: Y/N	This entire section (items in this table and the two tables that follow) would replace the current Grants and Other Resources Section on Page ID 2.2.4 in the General Monitoring Tool.
		Responses will be carried over across reporting periods. Grantees can edit if needed.
Does your opioid workgroup serve as your SPF-Rx Advisory Council?	Radio buttons: Y/N	This item will only appear if Yes is selected for the first item in this section. Responses will be carried over across reporting periods. Grantees can edit if needed.
Does a state/grantee-wide strategic plan exist addressing opioid issues, including prevention of misuse, treatment, and overdose prevention?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed.
Is there an opioid-focused taskforce out of your governor’s office?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed.
How has the opioid-focused taskforce out of your governor’s office informed the SPF-Rx project?	Free text	This item will only appear if Yes is selected for the previous item in this section.
Is your SPF-Rx strategic plan integrated into or harmonized with the state/grantee-wide opioid strategic plan?	Radio buttons: Y/N	This item will only appear if Yes is selected for the first item in this section. Responses will be carried over across reporting periods. Grantees can edit if needed.
Have you engaged in efforts to coordinate opioid funding streams during this reporting period?	Radio buttons: Y/N
Please describe your efforts to coordinate opioid funding streams during this reporting period?	Free text	This item will only appear if Yes is selected for the previous item in this section.

[STRUCTURE AND ITEMS FROM THIS TABLE WILL BE USED IN THE GENERAL MONITORING TOOL. ]

Source of Funding/Resources	Is Funding Source Received?	Funding Stream used for SPF-Rx Priorities in SPF-Rx Communities?
SAMHSA PFS	Radio buttons: Y/N	Radio buttons: Y/N
PDO/Naloxone	Radio buttons: Y/N	Radio buttons: Y/N
SAMHSA Medical-Assisted Treatment (MAT)	Radio buttons: Y/N	Radio buttons: Y/N
Health Resources and Services Administration (HRSA) Rural Opioid Overdose Reversal (ROOR)	Radio buttons: Y/N	Radio buttons: Y/N
CDC PfS	Radio buttons: Y/N	Radio buttons: Y/N
CDC DDPI	Radio buttons: Y/N	Radio buttons: Y/N
Drug-Free Communities	Radio buttons: Y/N	Radio buttons: Y/N
SAMHSA Minority HIV/AIDS Initiative	Radio buttons: Y/N	Radio buttons: Y/N
BJA Harold Rogers PDMP grant	Radio buttons: Y/N	Radio buttons: Y/N
Substance Abuse Prevention and Treatment Block Grant funds	Radio buttons: Y/N	Radio buttons: Y/N
State funds (excluding state Medicaid)	Radio buttons: Y/N	Radio buttons: Y/N
Municipal government funds	Radio buttons: Y/N	Radio buttons: Y/N
Foundation/Nonprofit organization funding	Radio buttons: Y/N	Radio buttons: Y/N
Other funds (specify)	Radio buttons: Y/N	Radio buttons: Y/N

4. Policies, Regulations, and Laws

[This Section is unique to SPF-Rx and would be inserted after Page ID 2.2.4.1 (Grantee and Other Resource Section) and before Page ID 2.2.5 (TTA section) in the General Monitoring Tool.]

Use this section to enter information regarding the existence of policies, regulations, and laws related to prescribing or dispensing opioids in your state, tribal area, or jurisdiction. Once you complete this section, you will only update it if there are any revisions or additional changes related to your policies, regulations, or laws.

Item	Type of Item/Response Options	Technical Notes
Indicate if guidelines/regulations currently exist in your state/jurisdiction related to any of the following: Required universal prescriber registration with the PDMP	Radio buttons: Y/N	Section is inserted after Page ID 2.2.4.1 (Grantee and Other Resource Section) and before Page ID 2.2.5 (TTA section) in the General Monitoring Tool
Doctors can assign authorized delegates to access the PDMP	Radio buttons: Y/N
Requirements for prescribers to query PDMP before prescribing opioids in certain conditions (e.g., for more than short-term use)	Radio buttons: Y/N
Pharmacists have a set time frame for uploading opioid dispensing data	Radio buttons: Y/N If yes, what is the time frame for uploading opioid dispensing data? (open text box)
PDMP patient records and electronic health records are linked in at least one large health care system	Radio buttons: Y/N
PDMP records are linked with vital records (e.g., deaths)	Radio buttons: Y/N
PDMP data can be used for public health surveillance, prevention, and research	Radio buttons: Y/N
PDMP produces regular reports that summarize key state or regional statistics of interest	Radio buttons: Y/N
PDMP produces unsolicited reports	Radio buttons: Y/N If yes, reports are for which groups? (Choose all that apply.) Dropdown list: Prescribers Dispensers Licensing boards Law enforcement agencies Other group(s) (Specify.)________________________________

(continued)

Item	Type of Item/Response Options	Technical Notes
Interstate agreements to share PDMP data	Radio buttons: Y/N
Requirements for prescribers to receive training on safe opioid prescribing	Radio buttons: Y/N
Limit to dose of opioid prescription (e.g., 90 MME/day) without special approval	Radio buttons: Y/N
Limit to the duration of opioid prescription for noncancer patients without special approval	Radio buttons: Y/N
Requirements that pain clinics must be regularly certified by the state medical board	Radio buttons: Y/N N/A (State does not have pain clinics)
Requirements that pain clinics must be owned and operated by a licensed physician	Radio buttons: Y/N N/A (State does not have pain clinics)
Other relevant PDMP guidelines or regulations not captured above?	Free text

5. Data Infrastructure

[This Section is unique to SPF-Rx and would be inserted after Page ID 2.2.4.1 (Grantee and Other Resource Section) and before Page ID 2.2.5 (TTA section) in the General Monitoring Tool—falls after SPF-Rx Guidelines and Regulations section above]

Use this section to enter information regarding data infrastructure and related activities.

Item	Type of Item/Response Options	Technical Notes
During this reporting period, have you engaged in efforts to:
… Enhance access to PDMP data at the grantee/state level?	Radio buttons: Y/N	Section inserted after Page ID 2.2.4.1 (Grantee and Other Resource Section) and before Page ID 2.2.5 (TTA section) in the General Monitoring Tool—falls after SPF-Rx Guidelines and Regulations section above
… Enhance access to PDMP data at the subrecipient level?	Radio buttons: Y/N
… Enhance usage of PDMP data at the grantee/state level?	Radio buttons: Y/N
… Enhance usage of PDMP data at the subrecipient level?	Radio buttons: Y/N
… Enhance the quality of PDMP data collected?	Radio buttons: Y/N
… Increase registration for the PDMP?	Radio buttons: Y/N
… Increase voluntary PDMP enrollment?	Radio buttons: Y/N
… Increase mandatory PDMP enrollment?	Radio buttons: Y/N
… Increase timely data upload by pharmacists to the PDMP?	Radio buttons: Y/N
… Integrate PDMPs with electronic health records?	Radio buttons: Y/N
… Integrate PDMPs with health information exchanges?	Radio buttons: Y/N
… Increase reports to prescribers?	Radio buttons: Y/N
… Increase reports to dispensers?	Radio buttons: Y/N
… Increase reports to licensing boards?	Radio buttons: Y/N
Please describe any other efforts to improve data infrastructure that have not been captured.	Free text

6. Training and Technical Assistance

[This Section will use the universal MRT items and structure on Page ID 2.2.5; however the intro text below should be used for the section.]

Use this section to record any T/TA sessions that have been provided to the grantee or subrecipients. Please note that this section does not include prescriber education trainings, which are reported in the Implementation section of this progress report and the Annual Implementation Instrument.

Training refers to the delivery of structured events focused on topics such as data collection protocols and systems and best practices in implementation.

Technical assistance refers to services provided by professionals to give programmatic and technical guidance to the grantee and/or subrecipients to effectively implement the SPF-Rx grant.

T/TA should be counted as one unit per issue. It does not include clarifying assistance (e.g., simply sending someone to a website).

7. Accomplishments and Barriers

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INSTRUCTIONAL LANGUAGE ACROSS PROGRAMS BUT DROPDOWN MENU VARYING BY PROGRAM—THESE ARE NOTED IN THE GENERAL MONITORING TOOL

4. Planning

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INTRO TEXT for PLANNING SECTION

1. Accomplishments and Barriers

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INSTRUCTIONAL LANGUAGE ACROSS PROGRAMS BUT DROPDOWN MENU VARYING BY PROGRAM—THESE ARE NOTED IN THE GENERAL MONITORING TOOL

UNIQUE ITEM FOR SPF-Rx INSERTED between PAGE ID 2.3 and PAGE ID 2.3.1]

Item	Type of Item/ Response Options	Technical Notes
Have you completed your Strategic Plan?	Radio buttons: Y/N	If No, skip remaining items in this section.
Were PDMP data incorporated into your strategic plan?	Radio buttons: Y/N

2. Strategic Plan Upload

GATHERED IN THE GENERAL MONITORING TOOL BUT PARAGRAPH BELOW SHOULD BE AFTER THE 1^ST SENTENCE IN THE GENERAL MONITORING TOOL INSTRUCTIONS.

Ensure that your strategic plan clearly explains how PDMP and/or other epidemiological data were used to identify communities with high rates of prescription drug misuse, focuses on improving PDMP partnerships and access/use of PDMP data, identifies data gaps, and addresses program sustainability.

5. Health Disparities

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INTRO TEXT for HEALTH DISPARITIES SECTION.

6. Implementation

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INTRO TEXT for IMPLEMENTATION SECTION

1. Implementation-Related Accomplishments and Barriers

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2. Use of Federal Toolkits/Guidelines

[This Section is unique to SPF-Rx and would be inserted after Page ID 2.4.1.1 (Implementation Accomplishments/Barriers)]

Federal resources have been developed that can assist grantees in training and increasing capacity around the prevention of opioid misuse and overdose. Please describe how the tools noted below were used.

Item	Type of Item/ Response Options	Notes
Did the grantee/state use SAMHSA’s Opioid Overdose Prevention Toolkit?	Radio buttons: Y/N	The items in this table would be inserted after Page ID 2.4.1.1 (Implementation Accomplishments/Barriers).
How was SAMHSA’s Opioid Overdose Prevention Toolkit used?	Free text	This item will only appear if Yes for prior item is selected.
Did the grantee/state use the CDC’s Guidelines for Prescribing Opioids for Chronic Pain?	Radio buttons: Y/N
How were the CDC’s Guidelines for Prescribing Opioids for Chronic Pain used?	Free text	This item will only appear if Yes for prior item is selected.

3. Subrecipients’ Promising Approaches and Innovations

GATHERED IN THE GENERAL MONITORING TOOL

4. Community-Based Social Marketing/Public Education Plan

[This Section is unique to SPF-Rx and would be inserted after Page ID 2.4.3 (SR Promising Approaches and Innovations)]

Upload and provide a brief description of your community-based social marketing/public education plan.

Community-Based Social Marketing/Public Education Plan Description

7. Evaluation

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INTRO TEXT AND OTHER SUBSECTIONS FOR EVALUATION SECTION

1. Evaluation Plan

GATHERED IN THE GENERAL MONITORING TOOL

2. Final Evaluation Report

GATHERED IN THE GENERAL MONITORING TOOL

3. Other Document Upload

GATHERED IN THE GENERAL MONITORING TOOL

4. Accomplishments and Barriers

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INSTRUCTIONAL LANGUAGE ACROSS PROGRAMS BUT DROPDOWN MENU VARYING BY PROGRAM—THESE ARE NOTED IN THE GENERAL MONITORING TOOL

8. Sustainability

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INTRO TEXT AND OTHER SUBSECTIONS FOR SUSTAINABILITY SECTION

1. Accomplishments and Barriers

GATHERED IN THE GENERAL MONITORING TOOL—COMMON INSTRUCTIONAL LANGUAGE ACROSS PROGRAMS BUT DROPDOWN MENU VARYING BY PROGRAM