Form PFS

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

DSP-MRT Supplement for PFS and PFS-M 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 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 Rm 15E57B, Rockville, Maryland, 20857.

Community-Level Outcome Data for Subrecipients

Use this section to enter community-level outcome data for your subrecipients. When you are ready to begin entering data on your subrecipients, select a subrecipient from the dropdown menu. Once you have added records, you will be able to view previously added records for the selected subrecipient.

If you are providing data to meet requirements for a specific PFS Required Outcome Measure, and your data source does not match the PFS Required Outcome exactly (survey item wording/response options or administrative data measure calculation), you are required to receive approval from your Project Officer for the substitute data source. Use the Substitute Data Source Request Page to submit a request for review and approval.

Click here to view the PFS Required Outcome Measures: [PFS REQUIRED OUTCOME MEASURES LINK HERE]

Click on the Add a Record button to enter data for a specific outcome measure. In the Record Listing, click on the Data Source Name link to edit a previously added record. Click on Add Follow-up Data to add follow-up data for a previously entered baseline record.

Add/Edit Community-Level Outcome Data for SubrecipientsXX

Item	Response
Subrecipient	Subrecipient 1 Subrecipient 2 Subrecipient 3 Etc.
Specified Substance	Alcohol Prescription drugs Other
Other Substance (If “Other” is selected)	Free text
PFS Required Outcome Measure	30-day use Past 12 month use Binge drinking Perception of parental or peer disapproval/attitude Perceived risk/harm of use Substance-related car crashes and injuries Substance-related crime Family communication Substance-related emergency room visits Other
Other Outcome Measure (If “Other” is selected)	Free text
Are you reporting an exact PFS Required Outcome, an approved substitute PFS Required Outcome, or neither?	Exact PFS Required Outcome Measure Approved substitute PFS Required Outcome Measure Not a PFS Required Outcome Measure or approved substitute
Data Source Type	Administrative data Survey data
Fields That Appear If "Administrative data" Is Selected in the Data Source Type Field
Data Source Name	Free text
Reported Outcome/Measure Calculation Description	Free text
Population Parameters	Enter age range Enter grade(s)
Age Range Minimum (If “Enter age range” is selected for Population Parameters) Insert the lower bounds for the age range for the population specified.	Numerical
Age Range Maximum (If “Enter age range” is selected for Population Parameters) Insert the upper bounds for the age range for the population specified. For example, if the outcome is alcohol-related motor vehicle crashes among young adults age 18 to 25, the maximum would be 25. If the population age range is bound at the lower but not the upper end (e.g., age 16 and older), the maximum should be entered as 99.	Numerical
Grades (If “Enter grade[s]” is selected for Population Parameters) (Check all that apply) Select the grade(s) of the population represented by the data. When possible, data for each specified grade should be reported separately. If the data reflect grade 7 students only, then select 7. If the data reflect students in grades 9 and 11 and the current data being reported are for grade 9 students, then select 9. If the data reflect students in grades 9 and 11, and the data are being reported together, select both 9 and 11.	K 1 2 3 4 5 6 7 8 9 10 11 12 College
Other Sample Descriptors	Free text
Data Source Time Frame Begin Date Insert a begin date (e.g., 10/1/2012) for the time period of the data you are submitting.	Date field
Data Source Time Frame End Date Insert an end date (e.g., 9/30/2013) for the time period of the data you are submitting.	Date field
Number of Events	Numerical
Denominator Definition	Free text
Denominator Value	Numerical
Value Type	Percentage Rate per 1,000 Rate per 10,000 Rate per 100,000 Other
Other Value Type (If “Other” is selected)	Free text
Calculated Value	Numerical
Comments	Free text
Fields That Appear If "Survey data" Is Selected in the Data Source Type Field
Data Source Name	Free text
Survey Item	Free text
Response Option(s)	Free text
Reported Outcome Description	Free text
Population Parameters	Enter age range Enter grade(s)
Age Range Minimum (If “Enter age range” is selected for Population Parameters) Insert the lower bounds for the age range for the population represented by the survey.	Numerical
Age Range Maximum (If “Enter age range” is selected for Population Parameters) Insert the upper bounds for the age range for the population represented by the survey. For example, if a survey was given to young adults age 18–25, then 25 should be entered as the maximum age. If the population age range is bound at the lower but not the upper end (e.g., age 16 and older), then 99 should be entered as the maximum age.	Numerical
Grades (If “Enter grade[s]” is selected for Population Parameters) (Check all that apply) Select the grade(s) of the population represented by the survey. When possible, data for each specified grade should be reported separately. If the survey was administered to grade 7 students only, then select 7. If the survey was administered to students in grades 9 and 11 and the current data being reported are for grade 9 students, then select 9. If the survey was administered to students in grades 9 and 11, and the data are being reported together, select both 9 and 11.	K 1 2 3 4 5 6 7 8 9 10 11 12 College
Other Sample Descriptors	Free text
Description of Sampling Design	Census Convenience sample Random sample Stratified random sample
Data Collection Date Indicate the month and year in which the survey was conducted. If the data collection took multiple months, the month at the middle of the period should be reported. If it took an even number of months, the middle month closer to the end date should be reported. If multiple years of data were combined into a single estimate due to small sample size, please insert the month and year of the most recent survey date and check "Multiple Year Pooled Estimate" below. If the data collection took multiple months, the month at the middle of the period should be reported. If it took an even number of months, the middle month closer to the end date should be reported. If multiple years of data were combined into a single estimate due to small sample size, please insert the month and year of the most recent survey date and check "Multiple Year Pooled Estimate" below. [Note: Use of multiyear estimates must be preapproved by CSAP.]	Date field
Multiple Year Pooled Estimate Indicate whether you are reporting data pooled across a number of years of survey data. Prior approval from CSAP must be received to report pooled multiyear estimates.	Yes No
Multiple Year Estimate Description: (If “Yes” is selected)	Free text
Value Type	Percentage Mean Other
Other Value Type (If “Other” is selected)	Free text
Calculated Value	Numerical
Standard Error	Numerical
Standard Deviation	Numerical
Survey Item Valid N	Numerical
Comments	Free text

Substitute Data Source Request

Use this section to obtain approval from your State Project Officer for the use of substitute outcome measures in place of PFS Required Outcome Measures.

Note that you are only required to submit a substitute data request for measures you are using to meet the annual exact/substitute measure requirement (one annual measure for alcohol and one for prescription drugs for each community). You do not need to submit a substitute data request for any of the other/additional measures you plan to submit.

To begin the substitute measure approval process:

First, decide whether your proposed substitute is likely to be approved. Click here to view the PFS Community Outcomes Guidance Manual. Table 3 of the manual shows the PFS Required Outcome Measures and Table 4 shows a comparison between PFS Required Outcome Measure survey items and items from commonly used surveys.

Note: If an item is listed in Table 4 as an acceptable PFS Required Outcome Measure substitute, you will not need to submit a substitute data request for the measure. If an item is not an acceptable PFS Required Outcome Measure, that item will not be accepted as a substitute data source.

Substitute Data Source Request Detail

Item	Response Options
In the MRT, grantees will click an “Add a Substitute Data Source Request” button to access the following required items for submitting a substitute data source request.
Submitter Name	Free text
Submitter Role	Project Director Grantee Evaluator Other
Other Role (Specify) (If “Other” is selected)	Free text
Submitter Email	Free text
Label of the PFS Required Outcome Measure(s) indicator for which grantee is requesting a substituted proxy measure (e.g., 30-day use of alcohol)	30-day alcohol use 30-day prescription drug misuse and abuse Past-year use Binge drinking Perception of parental or peer disapproval/attitude Perceived risk/harm of use School attendance and enrollment Alcohol- and drug-related crashes and injuries Alcohol- and drug-related crime Family communication around drug use Alcohol and prescription drug-related emergency room visits Other
Data source name	Free text
Exact wording of the proxy item and response options the grantee is requesting to substitute for the PFS Required Outcome Measure	Free text
Exact wording of the outcome that will be reported to SAMHSA/CSAP	Free text
Formulae for calculating or deriving the prevalence estimate (reported outcomes)	Free text
Summarize how the collection and reporting of community-level PFS Required Outcome Measure was written in your approved PFS Strategic Plan	Free text
Does the requested substitution differ from what was written in your approved PFS Strategic Plan?	Yes No
If yes, why? (If “Yes” is selected)	Free text
Reason for the substitution request	Free text
Agency/organization responsible for data collection	Free text
Who is substitute request for?	Grantee Subrecipient(s)
Subrecipient(s): (If “Subrecipient[s]” is chosen) (Check all that apply)	Subrecipient 1 Subrecipient 2 Subrecipient 3 Etc.
Data Source Type	Administrative data Survey data
Fields That Appear If "Survey data" Is Selected in the Data Source Type Field
Were there validity and reliability tests of the survey items constituting the substitute measure? Were validity and reliability tests conducted for the relevant survey item(s), either in previous studies/evaluations or for the purpose of SPF-PFS?	Yes No
Description of the reliability/validity study(ies): (If “Yes” is chosen)	Free text
Are there any published validity/reliability studies for this instrument? Were validity and reliability tests conducted for the survey instrument as a whole, either in previous studies/evaluations or for the purpose of SPF-PFS?	Yes No
Bibliographic Information: (If “Yes” is chosen)	Free text

Click on Grantee-Level Information or each subrecipient community below to complete additional questions related to grantee or subrecipient data. Once you have completed the questions for the grantee or for each subrecipient, you will be able to click the Submit button to submit your request. You may also click on the Supporting Documents link if you wish to submit documents related to your request.

Item	Response Options
In the MRT, grantees will select their subrecipients from a prepopulated list to access the following required items for submitting a substitute data source request.
Do the data approximate the community (e.g., county, city, town, school) where SPF-PFS interventions are delivered? Please report whether the boundaries within which data collection occurred approximately match the PFS community target area. For example, if the PFS community is a town within a larger county and the data are county-level data, select "No."	Yes No
If no, indicate how they differ (If “No” is selected)	Free text
Most recent month and year for which data are available?	Date field
Is there a data point collected at least 6 months prior to the implementation of SPF-PFS interventions in the community? (i.e., a baseline prevalence estimate)	Yes No
Is the data collection repeated every year?	Yes No
Frequency of data collection (If “No” is selected)	Free text
Are trend data available? Please select "Yes" if data are available for two or more timepoints prior to the baseline data point.	Yes No
Start year of trend data (If “Yes” is selected)	Date field
Fields That Appear If "Survey data" Is Selected in the Data Source Type Field in the Previous Section
Date of Data Collection	Date field
Sample Size	Numerical
Sampling Ratio	Free text
What type of sampling strategy was used to select respondents?	Census Convenience sample Random sample Stratified random sample
Stratified Sampling: -identify each stratum (If “Random sample” or “Stratified random sample” is selected)	Free text
Cluster Sampling: Identify the clustering unit (If “Random sample” or “Stratified random sample” is selected)	Free text
Multistage design: Identify the unit sampled at each stage (If “Random sample” or “Stratified random sample” is selected)	Free text
Potential sources of bias in the sample design (If “Random sample” or “Stratified random sample” is selected)	Free text
Method of Administration	Mail-in Telephone Face-to-Face Self-administered: school-based Self-administered: survey site other than school Other
Other Method (Specify) (If “Other” is selected)	Free text
Was this a computer-assisted interview?	Yes No
What was the survey response rate?	Free text

Substitute Data Source Request Supporting Documents

Upload documents to support your request. Include any reliability and validity data that are available.

Item	Response Option
Upload file	Browse button
For each data file, describe the contents of the data record(s) field that will be displayed	Free text

PFS Outcome Data Module: Print Version