Form Quarterly Progress Quarterly Progress Quarterly Progress Report

OMB No. 0930-0357 Expiration Date: 03/31/2019

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 4 hours 0 minutes 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, Rockville, Maryland, 20857.

MAI Quarterly Progress Report

1. Administration

Grantee Name: _______________________________________

Grantee Award Number: _______________________________

Cohort: ______________________________________________

Reporting Period (quarter, federal fiscal year): ______________

Address : _____________________________________________

City, State/Territory, Zip: ________________________________

Project Director Name: _________________________________

Project Director Email Address: ___________________________

Project Director Phone Number: __________________________

Project Coordinator Name: ______________________________

Project Coordinator Email Address: ________________________

Project Coordinator Phone Number: _______________________

Lead Evaluator Name: ______________________________

Lead Evaluator Email Address: ______________________________

Lead Evaluator Phone Number: __________________________________

2. Health Disparities

[Frequency: Completed twice every federal fiscal year, as part of the second- and fourth-quarter progress reports]

SAMHSA defines behavioral health as mental/emotional well-being and/or actions that affect wellness. The phrase “behavioral health” is also used to describe service systems that encompass prevention and promotion of emotional health; prevention of mental and substance use disorders, substance use, and related problems; treatments and services for mental and substance use disorders; and recovery support (for more information see: https://www.samhsa.gov/data/national-behavioral-health-quality-framework).

Healthy People 2020 defines health disparity as a “particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

In this section, we would like you to describe the efforts and activities that your state, tribe, or jurisdiction has undertaken in the project to address Behavioral Health Disparities related to HIV or substance use disorders risks, prevalence, and outcomes.

1. Cultural Competence and Behavioral Health Disparities Activities

1. Which of the following health disparities-related activities did your organization or institution conduct during this reporting period? (select all that apply)

• Conducted needs assessment activities specific to behavioral health disparities (e.g. identified subpopulations experiencing health disparities and their specific needs, collected data on identified subpopulations)

• Involved members of subpopulations experiencing behavioral health disparities in your CSAP/MAI activities, such as assessment, capacity building, planning, implementation, and evaluation

• Built organizational capacity for addressing behavioral health disparities (e.g. received trainings or built coalitions specifically for addressing disparities)

• Implemented strategies to address behavioral health disparities (e.g. interventions tailored to vulnerable subpopulations, efforts to increase access of vulnerable subpopulations to SA and HIV prevention and treatment services)

• Increased access to substance use and HIV prevention services for subpopulations experiencing behavioral health disparities (i.e., increased these populations' ability to get to or use these services). Increased access may refer to enhanced health coverage, services, timeliness, and workforce.

• Evaluated effects of implemented strategies on subpopulations experiencing behavioral health disparities

• Developed a plan to sustain progress made in addressing substance use and HIV-related health disparities beyond the CSAP/MAI grant

• Other (Specify) __________________________________________

1. Accomplishments and Barriers

1. what, if any, barriers are there to improving cultural competence in substance abuse and HIV prevention through your CSAP/MAI grant? (select all that apply)

• Limited availability of culturally-specific evidence-based interventions for the target group(s)

• Need for staff that are of the same race or ethnicity as the target group(s)

• Need for staff training that is culturally-specific to the target group(s)

• Lack of commitment to cultural competence by partner organizations

• Competing priorities under the CSAP/MAI grant

• Other (Specify) ______________________________

• No barriers

2. During this reporting period, what, if any, specific accomplishments have you made toward the goal of improving cultural competence and/or addressing behavioral health disparities in substance abuse and HIV prevention through your CSAP/MAI grant? (E.g. Translated informational materials or surveys into the language of your vulnerable subpopulations, added members of vulnerable subpopulations to your Advisory Board, trained your staff in meeting the target population's diverse racial, ethnic, cultural, age, sex/gender orientation, and disability challenges):

3. Conclusions and Recommendations (optional)

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ____________________________________

3. Assessment

[Frequency: Completed at least once during the Assessment phase and updated quarterly, as needed]

Assessment involves the systematic gathering and examination of data about alcohol and drug problems, related conditions and consequences in the area of concern to the community prevention planning group. Assessing the problems means pinpointing where the problems are in the community and the populations that are impacted. It also means examining the conditions within the community that put it at risk for the problems and identifying conditions that now or in the future could protect against the problems.

1. Community Needs Assessment Synopsis Information

1. Date Approved |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Target Community or Institution Name ____________________________________

3. Target Geographical Area (select all that apply)

• Large urban area (population of more than 500,000)

• Smaller urban area (population of 50,000 to 500,000)

• Small town or urban cluster (population or 2,500 to 50,000)

• Rural

• Tribal Area

• Campus

• Other (Specify) __________________________________

4. Target Gender (select all that apply)

• Male

• Female

• Transgender

• Other (Specify) ________________________________

5. Target Race (select all that apply)

• White

• Black/African American

• American Indian/Alaska Native (AI/AN)

• Native Hawaiian or Other Pacific Islander

• Asian

• Other (Specify) _______________________________________

6. Target Ethnicity (select all that apply)

• Hispanic or Latino

• Not Hispanic or Latino

7. Target Sexual Orientation (select all that apply)

• Straight or Heterosexual

• Bisexual

• Gay or Lesbian

• Other

8. Target Age Group (select all that apply)

• 12-15

• 16-17

• 18-20

• 21-24

• 25-29

• 30-39

• 40-49

• 50-59

• 60-69

• 70+

9. Target Population(s) (select all that apply)

• Adolescents (Age 12-17)

• Young Adults (Age 18-24) in college

• Young Adults (Age 18-24) not in college

• Older Adults (Age 50 and Over)

• American Indian/Alaska Natives (AI/AN)

• Native Hawaiian or Other Pacific Islander

• Black/African American Women

• Black/African American Men

• Latina or Hispanic Women

• Latino or Hispanic Men

• Men Having Sex with Men (MSM)

• LGBTQ2

• Military/Veterans

• Reentry Populations

• Homeless

• Sex Workers

• Low Income

• Other(s) (Specify) ___________________________________

10. Target Zip Codes ____________________________________________________

11. Description of Needs, Resources, Gaps _______________________________________

12. Findings of Epi Data __________________________________________________

13. Target Risk Factors/Target Protective Factors: (select all that apply)

• Attitudes supporting heavy alcohol use

• Attitudes supporting illicit drug use

• Attitudes supporting risky sexual behaviors

• Perceived risk of harm from unprotected sex

• Perceived risk of harm from heavy alcohol use

• Perceived risk of harm from illicit drug use

• Access to health services

• Awareness of health services

• Easy access to alcohol

• Positive alcohol expectancies

• Easy access to drugs

• Victimization

• Poor mental health

• Criminal justice involvement

• Experience with discrimination

• Life stress

• Early initiation of alcohol use

• Early initiation of drug use

• Injection drug use

• High knowledge of HIV

• Sexual self-efficacy

• High access to condoms or other forms of protection

• High social support

• Family connectedness

• Involvement with prosocial peer groups

• Positive intimate partner relationship

• Other(s) (Specify) __________________________

14. Targeted Capacity Expansion Type (select all that apply)

• Determining need based on data

• Developing prevention workforce

• Logically planning prevention services to address needs

• Providing evidence-based prevention services

• Evaluating prevention services delivered

15. Anticipated Impact of Targeted Capacity Expansion Type(s) on Organization’s Capacity (this item is optional) ________________________________________________

16. Upload/Attach your Needs Assessment Report

2. Community Needs Assessment Changes and Updates

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Change/Update Name ___________________________________

3. Description ____________________________________________

3. Accomplishments and Barriers

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one)

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name _________________________________________

3. Description ________________________________________________

4. Conclusions and Recommendations (optional)

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/Recommendation Name __________________________________________

3. Description of Conclusion/Recommendation ____________________________________

4. Capacity

[Frequency: Completed at least once during the Capacity Building phase and updated quarterly, as needed]

Capacity refers to the various types and levels of resources available to establish and maintain a sustainable community prevention system that can identify and leverage resources. Capacity to carry out prevention strategies depends not only upon the resources of the community organizations and their function as a cohesive problem-solving group, but also upon the readiness and ability of the larger community to commit its resources to addressing the identified problems.

1. Project, Organization/Institution, and Community Capacity

Staff Roster

Name	Date Joined	Position Title	FTE (Actual)	FTE (Approved)	Status	Date Exited (If Status is “Inactive”)
___________	Month|____|____| Day |____|____| Year|____|____|____|____	_______	__ __ %	__ __ %	Active Inactive	Month|____|____| Day |____|____| Year|____|____|____|____

Advisory Group and Governing Board Roster

Name	Date Joined	Affiliation	Member Type	Group Type	Status	Date Exited (If Status is “Inactive”)
___________	Month|____|____| Day |____|____| Year|____|____|____|____	________	Community Stakeholder Consumer	Project Advisory Group Governing Board	Active Inactive	Month|____|____| Day |____|____| Year|____|____|____|____

Collaborator Roster

Name	Date Joined	Collaborator Type	Gov’t Type (If Collaborator type is Government)	Organization Scope (If Collaborator type is Nongovernment)	Status	Date Exited (If Status is “Inactive”)
_________	Month|___|___| Day |___|___| Year|__|__|__|__	Government Nongovernment	Federal State Local	National Statewide Local	Active Inactive	Month|__|__| Day |__|__| Year|__|__|__|__

2. Project Advisory Council Meetings

1. Meeting Date|____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Meeting Name/Topic ______________________________________________

3. Upload/Attach agenda

4. Attendees: _______________________________________________________

________________________________________________________________

________________________________________________________________

3. Training and Technical Assistance (T/TA)

Instructions: Complete all items in this section separately for each T/TA event.

1. Date Requested|____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Status (select only one)

• Needed, not yet requested

• Requested

• Received

• Closed

3. Date Closed (completed If ‘Closed’ is selected for Status)

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

4. Training/TA Topic (select all that apply)

• Assessment

• Capacity

• Planning

• Implementation

• Evaluation

• Participatory Involvement

• Cultural Competence

• Sustainability

• Continuous Quality Improvement

• Other (Specify) __________________________________________

5. Select the option that best describes the delivery mechanism (select only one)

• Distance learning

• Technical assistance by telephone

• On-site/in-person technical assistance

• Technical assistance by email

• In-person class

• Conference or workshop

• Teleconference or telephone-based training

• Written materials

6. Select the option that best describes the source of assistance (select only one)

• PTTC

• CSAP Project Officer

• SPARS

• State Prevention Organization

• Other (Specify) _____________________________________________

7. Was the Training/TA provided in a timely and effective manner (select only one)

• Yes

• No (please explain) _____________________________________

8. Description __________________________________________________________

4. Accomplishments and Barriers

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one)

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name _________________________________________

3. Description ________________________________________________

5. Conclusions and Recommendations (optional)

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

5. Planning

[Frequency: Completed at least once during the Planning phase and updated quarterly, as needed]

Planning involves following logical sequential steps designed to produce specific results. The desired results (Outcomes) are based upon data obtained from a formal assessment of needs and resources. The plan, then, outlines what will be done over time to create the desired change.

1. Strategic Prevention Plan Synopsis

1. Date Approved |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Over the life of the grant, estimate the total number of people you plan to serve through direct service interventions: ________

3. Over the life of the grant, estimate the number of people you plan to serve through direct service interventions by target population (Enter the number planned to serve by target population in the second column below; note, the number planned to serve for any given target population should not exceed the total planned to serve entered above in item 5.1.2):

Target Population	Number Planned to Serve
Adolescents (Age 12-17)
Young Adults (Age 18-24) in college
Young Adults (Age 18-24) not in college
Older Adults (Age 50 and Over)
American Indian/Alaska Natives
Native Hawaiian or Other Pacific Islander
Black/African American Women
Black/African American Men
Latina or Hispanic Women
Latino or Hispanic Men
Men Having Sex with Men (MSM)
LGBTQ2
Military/Veterans
Reentry Populations
Homeless
Sex Workers
Low Income
Other

(Number planned to serve for any given target population cannot exceed the total planned to serve through direct service interventions)

4. Workplan/Timeline Description _________________________________________________

5. Explain how substance abuse and HIV prevention services will be integrated: ______________

6. Upload/Attach your Strategic Plan

2. Goals, Objectives, and Outcome Categories

1. Targeted Goal(s) (select all that apply)

• Increase capacity to provide substance abuse, HIV, or viral hepatitis prevention services

• Prevent, slow the progress, and reduce the negative consequences of substance abuse

• Prevent, slow the progress, and reduce the negative consequences of HIV or viral hepatitis transmission

• Reduce health disparities in the community

Instructions: For each goal that you are targeting, complete the objectives roster, select outcome categories, and outcome measures. For goals that you are not targeting, leave the objectives and outcomes blank.

Goal: Increase capacity to provide substance abuse, HIV, or viral hepatitis prevention services

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ____________________ Objective Description: ____________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Goal: Prevent, slow the progress, and reduce the negative consequences of substance abuse

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ___________________ Objective Description: ____________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Outcome Category (select one or more)

• Perception of risk of harm from substance abuse (participant level)

• Disapproval of substance abuse (participant level)

• Other substance abuse risk/protective factors (participant level)

• Past-30 day substance use (participant level)

• Consequences of substance abuse (participant level)

• Substance abuse related community-level outcomes

Goal: Prevent, slow the progress, and reduce the negative consequences of HIV or viral hepatitis transmission

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ___________________ Objective Description: ___________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Outcome Category (select one or more)

• HIV Knowledge, beliefs, and attitudes (participant level)

• Risky sexual behaviors (participant level)

• Other HIV or viral hepatitis risk/protective factors (participant level)

• HIV or viral hepatitis related community-level outcomes

Goal: Reduce behavioral health disparities in the community

Objective(s) (enter one or more objectives in the below roster)

Objective Description	Date Started	Planned Completion Date	Current Status	Date Completed (If Status is “Completed” or “Exceeded target”)
Objective Name: ___________________ Objective Description: ___________________	Month|____|____| Day |____|____| Year|____|____|____|____	Month|____|____| Day |____|____| Year|____|____|____|____	Not started Less than half completed Half completed More than half completed Completed Exceeded target	Month|____|____| Day |____|____| Year|____|____|____|____

Outcome Category (select one or more)

• Access to services (participant level)

• Community-level measures of behavioral health disparities

3. Direct Service Intervention Planning

Instructions: Complete all items in this section separately for each direct service intervention you are planning. In this context, “intervention,” refers to an activity or a set of coordinated activities to which a group or individual is exposed to in order to change their behavior or their knowledge/attitudes associated with behavior change.

1. Direct Service Intervention Name (See “Direct Service Intervention Name List” attachment for a list of direct service intervention names. Please enter the name exactly as it appears on the list. If your planned direct service intervention is not included on the list, please write it in on the “Other” line below) _____________________________________________

Other: ________________________________________

2. Date Added |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Objectives (enter the name of the objectives you identified in Section 5.2 that are relevant to this direct service intervention):

_______________________________________

4. Intervention Target(s) (select all that apply)

• SA

• HIV

• Viral hepatitis

• Other (Specify) _______________________________________

5. Intervention Description _____________________________________________________

6. Does this direct service intervention target (select only one)

• Individuals

• Community

• Both

7. Is this direct service intervention evidence-based? (select only one)

• Yes

• No

8. Evidence-based Justification (completed if “Yes” is selected for “Is this direct service intervention evidence-based?”; select all that apply)

• Inclusion in a Federal List or Registry of evidence-based interventions or other evidence-based practice resource center

• Being reported (with positive effects) in a peer reviewed journal

• Documentation of effectiveness based on all three of the following criteria: 1) based on solid theory validated by research; 2) supported by a body of knowledge generated from similar interventions; 3) consensus among informed experts of effectiveness based on theory, research, practice, and experience

9. Do you plan to adapt this direct service intervention from the original? (completed if “Yes” is selected for “Is this direct service intervention evidence-based?”; select only one)

• Yes

• No

10. Description of Adaptation_____________________________________________________

(completed when “Yes” is selected for “Do you plan to adapt this direct service intervention from the original?”)

11. Status (select only one)

• Active

• Inactive

12. Planned Direct Service Intervention Begin Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

13. Number of Sessions Planned (Frequency) ____________

(Enter a number to indicate the number of sessions planned for this direct service intervention per participant (for individual-format services) or group of participants (for group-format services). For example, if you are planning to provide 15 sessions for each person in the intervention, enter 15)

14. Number of Minutes Planned (Dosage) _____________

(Enter a number to indicate the number of minutes planned for all sessions of this direct service intervention per participant, rounded to the nearest 5 minutes (e.g., if you are planning to implement 900 minutes for each person in the intervention, enter 900 here).)

4. HIV Testing Planning

1. How does your organization plan to provide HIV testing services? (select all that apply)

• Rapid HIV testing will be provided by the grantee organization

• Rapid HIV testing will be available through referral to an outside organization

• Confirmatory HIV testing will be available through referral to an outside organization

2. Please describe how HIV testing will be conducted and where (e.g. off site, local health department, subcontract, hospital, etc.): ____________________________________

3. How many people do you expect will receive an HIV test using CSAP/MAI grant funds? _______

5. Viral Hepatitis (VH) Testing Planning

1. How does your organization plan to provide VH testing services? (select all that apply)

• Rapid VH testing will be provided by the grantee organization

• Rapid VH testing will be available through referral to an outside organization

• Confirmatory VH testing will be available through referral to an outside organization

2. Please describe how VH testing will be conducted and where (e.g. off site, local health department, subcontract, hospital, etc.): ____________________________________

3. How many people do you expect will receive a VH test using CSAP/MAI grant funds? _______

6. Viral Hepatitis (VH) Vaccination Planning

[NOTE: This section is for HIV CBI grantees only and is optional]

1. How does your organization plan to provide VH vaccination services? (select all that apply)

• VH vaccinations will be provided by the grantee organization

• VH vaccinations will be available through referral to an outside organization

2. Please describe how VH vaccinations will be conducted and where (e.g. off site, local health department, subcontract, hospital, etc.): ____________________________________

3. How many people do you expect will receive a VH vaccination using CSAP/MAI grant funds? _______

7. Indirect Service Planning

Definitions:

Indirect Service: A prevention activity intended to change the institutions, policies, norms, and practices of entire community or to disseminate information to the entire community. Typically, the service is delivered to an entire population rather than a specific individual or a group and the service provider and service recipients are not necessarily in the same location at the same time.

Environmental Strategy: A prevention activity intended to change community standards, codes, and practices, related to undesirable health behaviors in the general population (e.g. changes in rules and regulations or systems changes at the organization or community level).

Information Dissemination: A prevention activity intended to provide knowledge about undesirable health behaviors and their adverse effects, or about available behavioral health services, to an entire community (e.g. media campaigns, informational brochures, posters, web sites, etc.)

Instructions: Complete all items in this section separately for each Indirect Service you are planning.

1. Date Added |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Objective(s) (list the objective(s) you identified in Section 5.2 that are relevant to this indirect service)

_______________________________________

_______________________________________

_______________________________________

3. Indirect Service Type (select only one)

• Environmental Strategy

• Information Dissemination

4. Indirect Service

If Environmental Strategy is selected as the Indirect Service Type, select one of the following indirect services:

• Efforts to improve neighborhood or campus safety

• Enhancing accesses to SA/HIV/VH prevention services

• Enhancing access to opioid reversal devices

• Enforcement efforts (e.g. compliance checks, sobriety checkpoints, dormitory inspections)

• Collaboration with law enforcement

• Educating elected officials or other community leaders

• Training environmental influencers (e.g. police, beverage servers, healthcare providers, campus administrators)

• Efforts to increase sanctions for alcohol or drug use

• Condom distribution

• Enhancing access to HIV and/or viral hepatitis testing through health policy or organizational change

• Promoting changes to alcohol pricing and/or taxation

• Gathering of Native Americans (GONA)

• Promoting policy changes to limit alcohol advertising

• Promoting policy changes (e.g. in workplaces or campuses) to prevent sexual violence

• Other efforts to change community or organizational policies

• Other (Specify) ____________________________________

If Information Dissemination is selected as Indirect Service Type, select one of the following indirect services:

• Public speeches or lectures

• Town hall meetings

• Social marketing or social norms campaigns

• Prevention-focused websites

• Information dissemination through social media (e.g. Facebook, Twitter, YouTube)

• E-mail blasts

• Instagram

• Applications for mobile devices (e.g. Smart phones, tablets)

• Posters or billboards

• Public service announcements (PSA) on radio or television

• Newspaper or magazine advertisements

• Newspaper articles or letters to the editor

• Informational booklets, brochures, flyers or newsletters

• Workshops, seminars, or symposiums

• Health fairs

• Condom demonstrations

• Health & fitness promotions and demonstrations

• Information phone lines or hotlines

• Tabling

• Other (specify) __________________________________

5. What does this indirect service target? (select all that apply)

• SA

• HIV

• Viral hepatitis

• Other (Specify) ___________________________________

6. Environmental Strategy Purpose (completed if Environmental Strategy is selected for Indirect Service Type; select all that apply)

• Limit access to substances

• Change culture and context within which decisions about substance use or sexual behaviors are made

• Change physical design of the environment (e.g. improve lighting, add emergency phones)

• Reduce negative consequences associated with substance use or risky sexual behaviors

• Reduce morbidity and mortality related to opioid overdose

• Enhance access or reduce barriers to prevention and healthcare resources

• Increase access to condoms or other forms of protection

• Change social norms

• Reduce glamorization of substance abuse

• Increase pricing of alcohol

• Increase penalties or sanctions

• Capacity/coalition building

• Educate for policy change

• Increased access to viral hepatitis vaccine

• Other (Specify) ___________________________

7. Information Dissemination Purpose (completed if Information Dissemination is selected for Indirect Service Type; select all that apply)

• To raise awareness of substance abuse, HIV, or viral hepatitis related problems in the community

• To gain support from the community for your prevention efforts

• To provide information on community norms related to substance use or sexual behaviors

• To provide information on the harms of substance use or risky sexual behaviors

• To provide information on how to prevent substance abuse or HIV/VH transmission among family and friends

• To change individual behaviors with regard to substance use or risky sexual behaviors

• To provide intervention program information (e.g., contact information, meeting times)

• To provide surveillance and monitoring information (e.g., information about whom to contact if you witness underage alcohol sales or consumption)

• To provide information about prevention and healthcare resources in the community

• To educate for policy change

• Other (Specify) ____________________________________________

8. Indirect Service Description ___________________________________________

9. Planned Indirect Service Begin Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

10. Planned Indirect Service End Date

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

11. How many people do you plan to reach through this indirect service? _________

12. Is this indirect service evidence-based? (select only one)

• Yes

• No

13. Evidence-based Justification (completed if “Yes” is selected for “Is this indirect service evidence-based?”; select all that apply)

• Inclusion in a Federal List or Registry of evidence-based interventions or other evidence-based practices resource center

• Being reported (with positive effects) in a peer reviewed journal

• Documentation of effectiveness based on all three of the following criteria: 1) based on solid theory validated by research; 2) supported by a body of knowledge generated from similar interventions; 3) consensus among informed experts of effectiveness based on theory, research, practice, and experience

8. Accomplishments and Barriers

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one)

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name _________________________________________

3. Description ________________________________________________

9. Conclusions and Recommendations (optional)

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

6. Implementation

[Frequency: Completed quarterly during the Implementation phase]

Implementation is the point at which the activities developed and defined in the Assessment, Capacity, and Planning steps are conducted.

1. Numbers Served

Numbers served are collected using the participant level instrument. (Note: if technically possible, summary data from the participant level instruments will display here using the table from the planning section as a template)

2. Numbers Reached

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this federal fiscal year, how many people did you reach through indirect services? _________

3. So far this federal fiscal year, how many people did you reach through indirect service interventions, by the following demographic categories? (Enter the number reached by demographic category in the second column below. If you do not know the exact number, please make your best estimate. Note, the number reached for any given demographic category should not exceed the total reached you entered above):

Demographic Category		Number Reached
Gender Identity	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American or Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	More than One Race
	Unknown
Age	Ages 12-17
	Ages 18 or Older
	Unknown

4. Is the number of people reached from indirect service interventions actual or an estimate? (select only one)

• Actual

• Estimate

3. Grant Expenditures

1. Date Updated |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. So far this reporting period, how many of the following did your agency purchase using CSAP/MAI grant funds?

1. HIV test kits _____

2. VH test kits _____

3. VH vaccines _____

3. So far this reporting period, how many grant dollars were spent on …

Direct Services Implementation	$
Indirect Services Implementation	$
HIV Testing	$
VH Testing	$
VH Vaccinations	$
Other Expenses (Specify)_______________	$
Total Grant Dollars Spent	$ (auto sum)

4. Direct Service Intervention Implementation

Instructions: Complete this section separately for each implementation of each direct service intervention you listed in Section 5.3. Each time a direct service intervention is implemented on a different group of individuals, it counts as a separate implementation of that intervention. E.g., if a health education curriculum is delivered to three different groups, each of those count as a separate implementation of the intervention.

1. Date Implementation Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Date Implementation Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Direct Service Intervention Name (Enter the Intervention Name you listed in Section 5.3) _______________________________________

4. Were all direct services/topics/sessions from the planned intervention covered?

• Yes

• No

5. How did the direct services/ topics/sessions differ from what was planned? _____________

(completed if “No” is selected for the question: Were all direct services/topics/sessions from the planned intervention covered?)

6. What are the reasons the intervention differed from planned? _______________________

(completed if “No” is selected for the question: Were all direct services/topics/sessions from the planned intervention covered?)

7. Retention Activities __________________________________________________________

8. Incentives to participants (select all that apply)

• Merchant Gift Cards

• Transportation

• Evaluation Incentives

• Other (Specify) __________________________________

9. Number of Sessions (Frequency) ____________________________________________ (Enter a number to indicate the number of sessions conducted for this direct service intervention per participant (for individual-format services) or group of participants (for group-format services). For example, if you provided 15 sessions for each person in the intervention, enter 15)

10. Number of Minutes (Dosage) _______________________________________________ (Enter a number to indicate the number of minutes spent delivering all sessions of this direct service intervention per participant, rounded to the nearest 5 minutes (e.g., if you met for 900 minutes with each person in the intervention, enter 900 here).)

5. HIV Testing Implementation

Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

So far this federal fiscal year, how many people received an HIV test using funds from this grant? __________

Of the total tested for HIV mentioned above [i.e., total number of people who received an HIV test using funds from this grant], how many were:

Demographic Category		Number
Gender Identity	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American or Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	More than One Race
	Unknown
Age	Ages 12-17
	Ages 18-24
	25 years or older
	Unknown
Homeless	Homeless or Unstably Housed
Test Information	Tested for the 1st time
	Test Results Positive
	Informed of HIV Status
	Tested positive and was referred to treatment

6. Viral Hepatitis (VH) C Testing Implementation

Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

So far this federal fiscal year, how many people received a VH test using funds from this grant? _____________

Of the total tested for VH mentioned above [i.e., total number of people who received a VH test using funds from this grant], how many were:

Demographic Category		Number
Gender Identity	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American or Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	More than One Race
	Unknown
Age	Ages 12-17
	Ages 18-24
	25 years or older
	Unknown
Homeless	Homeless or Unstably Housed
Test Information	Tested for the 1st time
	Test Results Positive
	Informed of VH Status
	Tested positive and was referred to treatment

7. Viral Hepatitis (VH) C Vaccination Implementation

Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

So far this federal fiscal year, how many people received a VH vaccination using funds from this grant? _____________

Of the total for VH Vaccinations mentioned above [i.e., total number of people who received a VH vaccination using funds from this grant], how many were:

Demographic Category		Number
Gender Identity	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American or Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	More than One Race
	Unknown
Age	Ages 12-17
	Ages 18-24
	25 year older
	Unknown
Homeless	Homeless or Unstably Housed

8. Referrals for Services Not Funded by MAI Funds

Referrals are collected using the participant level instrument. (Note: if technically possible, summary data from the participant level instruments will display here summarizing Section C in the Records Management Section)

9. Indirect Service Implementation

Instructions: Complete this section separately for each time you implement each Indirect Service you entered in Section 5.7.

1. Date Service Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Date Service Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Indirect Service (Enter the Indirect Service you listed in Section 5.7) _______________________________________

4. Did implementation of this indirect service go according to plan?

• Yes

• No

5. How did implementation differ from the planned indirect service? _______________________

(completed if “No” is selected for the question: Did Implementation of this indirect service go according to plan?)

6. What are the reasons this indirect service differed from planned? _______________________

(completed if “No” is selected for the question: Did Implementation of this indirect service go according to plan?)

10. Participant Outreach/Recruitment Activities

Instructions: Complete this section separately for each outreach/recruitment activity conducted during the quarter.

1. Date Activity Started |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Date Activity Ended |____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. Activity Name ________________________________________________

4. Activity Description ________________________________________________________

5. During this quarter, how many people did you reach through these recruitment activities? ________

11. Promising Approaches and Innovations

Instructions: Use this section to enter information on any promising approaches or innovations demonstrated during your implementation of the grant. Only update this section if you implemented new promising approaches or innovations during this reporting period.

1. Promising Approach or Innovation Name _________________________________

2. Briefly describe the promising approach or innovation implemented ______________________

12. Accomplishments and Barriers

Enter information on any Accomplishments and/or Barriers that you had while performing activities related to Implementation.

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one)

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name ___________________________

3. Description ________________________________________________

13. Conclusions and Recommendations (optional)

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

7. Evaluation

[Frequency: Completed at least once during the Evaluation phase, updated as needed]

The Evaluation Step is comprised of conducting, analyzing, reporting on and using the results of Outcome Evaluation. The Outcome Evaluation involves collecting and analyzing information about whether the intended Goals and Objectives were achieved. Evaluation results identify areas where modifications to prevention strategies may be needed, and can be used to help plan for sustaining the prevention effort as well as future endeavors.

1. Evaluation Plan

1. Upload/Attach Evaluation Plan

2. Upload/Attach Supporting Documents

2. Evaluation Report

1. Upload/Attach Evaluation Report

2. Is this Evaluation Report a draft or final version? (select only one)

• Draft

• Final Version

3. Upload/Attach Supporting Documents

3. Accomplishments and Barriers

1. Type (fill out this section separately for each additional accomplishment or barrier; select only one)

• Accomplishment

• Barrier

2. Accomplishment/Barrier Name _________________________________________

3. Description ________________________________________________

4. Conclusions and Recommendations (optional)

1. Date Identified |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. Conclusion/ Recommendation Name __________________________________________

3. Description of Conclusion/ Recommendation ______________________________________

5. Closeout Evaluation Report

This section is only required at closeout. As you complete your closeout evaluation report, consider how your interventions addressed the goals of MAI. Think about key areas such as capacity building, substance abuse prevention, HIV/VH prevention, reducing health disparities, etc. Be sure to include information on anything that was interesting or surprising about your findings. Were there any implementation issues that could explain your findings? How about contextual, population, and other variables? Are there any questions that these findings raise? What are the implications of these findings? As you answer the questions below, please be sure to make a logical connection between evaluation findings and conclusions/recommendations. This is an opportunity for SAMHSA to learn about your project and to use evaluation findings for future efforts.

After you answer all questions, upload any supporting documents (if applicable).

1. What were your key accomplishments, strengths, or special achievements? ________________

2. Describe any major problems, issues, challenges, or barriers you encountered: ______________

______________________________________________________________________________

3. Describe your dissemination strategies: ______________________________________________

4. What actions have you taken to ensure sustainability after your Federal MAI grant funding ends? ______________________________________________________________________________

5. What were your lessons learned and/or what suggestions do you have for us to improve MAI going forward? __________________________________________________________________

6. Upload/Attach Supporting Documents

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