Form Annual Implementat Annual Implementat Annual Implementation Instrument
Strategic Prevention Framework for Prescription Drugs (SPF-Rx)
Attachment 1_SPF-RxAnnualImplementationInstrument_11.21.19
Annual Implementation Instrument
OMB: 0930-0377
SPF‑Rx Cross-Site Evaluation, Annual Implementation Instrument
Form Approved OMB
No. 030-0377 Expiration
Date 08/31/2020
Strategic
Prevention Framework
for Prescription Drugs
(SPF‑Rx)
Annual Implementation Instrument (AII)
November 2019
Substance Abuse and Mental
Health Services Administration
Center for Substance Abuse
Prevention
Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of the Strategic Prevention Framework Prescription Drugs (SPF-Rx) grant program. This voluntary information collection will be used at an aggregate level to determine the reach, consistency, and quality of the SPF-Rx Program. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0377. Public reporting burden for this collection of information is estimated to average 4 hours and per response, 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 Ln, Room 15 E57B, Rockville, MD 20857.
NOTE Timing of Instrument Items: E = Every time (annually). B = Baseline only. F = Final only.
Section 1: Administrative Survey 6
Organization Type (Subrecipients only) 6
PFS Funding History (Subrecipients only) 7
Section 2: Strategic Prevention Framework 8
Section 2A. Needs, Population of Focus, and Resources Assessments 8
Needs Assessment (Subrecipients only) 8
Data Sources (Subrecipients only) 8
Targeted Populations and Outcomes (Both grantees and subrecipients complete) 11
Section 2B. Capacity Building and Sustainability (Subrecipients only) 15
Current Capacity (Subrecipients only) 15
Training and Technical Assistance (Subrecipients only) 16
Development of SPF‑Rx Organizational Resources (Subrecipients only) 17
Relationship Building (Subrecipients only) 18
Data Infrastructure (Subrecipients only) 21
Sustainability (Subrecipients only) 23
Section 2C. Prevention Intervention Implementation (Both grantees and subrecipients complete) 24
Implemented Prevention Interventions 25
Prevention Intervention and Service Type Information 27
Community-Based Processes Sub-Form 31
Prevention Education Sub-Form 33
Alternative Drug-Free Activities Sub-Form 36
Problem Identification and Referral Sub-Form 40
Environmental Strategies Sub-Form 43
I. Training and educating environmental influencers 43
II. Policy, regulation, or law enactment or implementation 45
III. Enforcement implementation 50
IV. Other environmental interventions 51
(Questions 98–101 have been deleted.) 53
Information Dissemination Sub-Form 53
(Questions 121–124 have been deleted.) 59
Section 2D. Monitoring and Evaluation (Subrecipients only) 60
Section 4: Closing Questions (Both grantees and subrecipients complete) 64
Strategic Prevention Framework for
Prescription Drugs (SPF‑Rx)
Cross-Site Evaluation, Annual
Implementation Instrument (AII)
The Annual Implementation Instrument collects data annually from primary SPF‑Rx grantees and their subrecipient communities about SPF‑Rx implementation, including:
Subrecipient communities’ progress through the Strategic Prevention Framework (SPF); and
The specific prevention interventions being implemented by subrecipient communities and primary grantees. For SPF‑Rx, interventions may be implemented by primary grantees as well as their community subrecipients.
Subrecipient communities will complete the whole survey, while primary grantees will mainly report on prevention interventions that they implement. Data collected from the survey will be used to monitor subrecipient and state, tribal entity, or jurisdiction performance and evaluate the effectiveness of the Strategic Prevention Framework for Prescription Drugs (SPF‑Rx) program across states, tribal entities, and jurisdictions. The overall goal of the cross-site evaluation is to document and assess the effectiveness of the SPF‑Rx approach to SAMHSA’s mission of reducing prescription drug misuse and abuse.
Completion of this survey is a requirement of accepting funding from CSAP through your state, tribal entity, or jurisdiction under the SPF‑Rx grant initiative.
Make sure to read all of the directions and examples, which are provided in italics. Primary grantees and subrecipient communities will complete this form once for each Federal fiscal year (annually). To minimize respondent burden and decrease completion time, this web-based survey allows information entered in previous reporting periods to be prefilled where possible and uses skip patterns to take you automatically to the appropriate question on the basis of your responses.
You will need to complete separate forms related to implementation information for each set of prevention intervention activities implemented. For example, if your community/jurisdiction implements both a participant-based education prevention intervention strategy and an environmental prevention intervention strategy, you will complete implementation information for both of those interventions. Similarly, if your community implements two different participant-based prevention education intervention strategies, you will complete implementation information for both of those interventions.
Information provided in this instrument focuses on communities, so no individuals will be identified in the reporting of results.
Throughout this instrument, the term “you” refers to the primary SPF‑Rx grantee (state/tribal entity/jurisdiction) or the subrecipient community that has received SPF‑Rx funding from the state/tribal entity/jurisdiction. The SPF‑Rx subrecipient community could be an organization, coalition, or other entity.
You are strongly encouraged to obtain input from others involved with the SPF‑Rx-funded project at the grantee and/or subrecipient level. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, as appropriate and relevant for your SPF‑Rx grant.
People you may want to include in responding to this survey (if these positions are applicable to your grant)—
Project Director
Project Coordinator
Person with responsibility or knowledge of financial issues
State Epidemiology and Outcomes Workgroup (SEOW) Liaison
Data Coordinator
Local Evaluator
Intervention delivery staff
Coalition representatives
Key stakeholders or partners
Before completing the survey, you may find it helpful to gather the following materials to help answer questions:
Budgets;
Results of needs and resources assessments;
Strategic plans;
Meeting minutes;
Memoranda of understanding;
Prevention intervention implementation materials (curricula, programs, etc.);
Evaluation findings and reports; and
Organizational policies.
As you enter your data, you will be able to save your work and come back to it at another time. We recommend that you write your responses to the open-ended questions requiring narrative information in advance using a word processor and copy and paste them into the web-based survey.
If you need assistance in using the web-based data entry system, contact the Help Desk by leaving a message at 877-439-1211or by email at [email protected]
. You can request assistance at any time and someone will respond to you within 24 hours or the next business day.
The following are definitions for several terms used throughout this instrument. Links to the definitions list can also be found on each page of the web-based survey.
Capacity refers to the quality and/or level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF‑Rx, capacity refers to the demonstrated ability of subrecipients to implement each SPF step effectively (e.g., implementation of evidence-based interventions) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model.
Capacity building refers to activities conducted to improve the ability of an organization or community to deliver prescription drug misuse prevention services, such as improving organizational resources; improving awareness about prescription drug misuse problems; building new relationships or strengthening existing relationships among coalitions, groups, and organizations involved in prescription drug misuse prevention; and working to ensure that prevention intervention activities and outcomes continue after funding ends.
Community refers to the politically or geographically defined area or culturally or epidemiologically defined population of focus that the subrecipient chooses for each prevention intervention.
Community needs and resources assessments examine needs and resources external to the organization and include community readiness (definition below), rates of prescription drug and opioid misuse, prevention resources (e.g., call centers, trained implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.
Community readiness is the community's level of awareness of, interest in, and ability and willingness to support prescription drug misuse prevention initiatives. More broadly, it connotes readiness for changes in community knowledge, attitudes, motives, policies, and actions.
Consequences are defined as the social, economic, and health problems associated with misuse and abuse of prescription drugs—for example, overdoses and deaths related to prescription drugs.
Consumption patterns are the ways in which people misuse prescription drugs.
Cultural competence is the knowledge, skills, and attitudes that enable administrators and practitioners to provide for diverse or culturally distinct populations. It includes an understanding of that group’s or members’ language, beliefs, norms, and values, as well as socioeconomic and political factors that may have a significant impact on their well-being, and the ability to incorporate those variables into interventions.
Directly served.individual-based prevention strategies or services directly delivered to individuals, either on a one-on-one basis or in a group format. Typically, the service provider and the participant are at the same location during the service encounter. Examples include training sessions and educational classesrefers to
Dosage describes the level of exposure to an intervention, as defined by the number of sessions, number of media spots, or other measures.
Environmental approaches are efforts to establish or change community standards, codes, and attitudes and thus reduce the incidence and prevalence of prescription drug misuse. Approaches can center on legal and regulatory issues or can relate to service and action-oriented initiatives. Examples include technical assistance (TA) to communities to increase health care provider’s use of prescription drug monitoring program data when prescribing opioid pain medication.
Federal fiscal year goes from October 1 through September 30 of the following year.
Indirectly reached.such as the Census or media outlets. Common indirect strategies include information dissemination and environmental strategiesimpacted by the services, counts of people reached are typically estimates obtained from sources describes population-based prevention strategies aimed at impacting an entire population. Since there is no direct interaction between the populations
Intervening variables are risk or protective factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of prescription drug misuse and related risk behaviors and their consequences. These variables are the focus of prevention interventions, changes in which are then expected to affect consumption and consequences.
In-kind resources include labor that supports the SPF‑Rx grant at subsidized or no cost to the grant or other resources donated to the SPF‑Rx grant, such as equipment, supplies, or office space.
Interventions are funded activities carried out under the auspices of the SPF‑Rx grant. They target a variety of subpopulations with the objective of improving outcomes related to prescription drug and opioid misuse and abuse.
Key stakeholders are all the members of the community who have a vested interest (a stake) in the activities or outcomes of a prescription drug misuse prevention intervention.
Leveraging resources is the process of combining SPF‑Rx-funded resources with other resources to augment prevention intervention delivery (i.e., to do more together than with SPF‑Rx resources alone). For example, subrecipients combine SPF‑Rx funding with funding from another source (e.g., CDC Prevention for States) to augment the implementation of their SPF‑Rx intervention. In many instances, leveraging functions through collaborative relationships.
Participants are the recipients of the SPF‑Rx prevention interventions.
Primary grantee or grantee refers to the administrative entity (such as the state, tribal entity, or jurisdiction) receiving SPF‑Rx funds for delivery of prescription drug misuse prevention interventions.
Social marketing uses the principles of commercial marketing to develop, implement, and evaluate interventions designed to influence the behavior of a target audience.
Strategic plans at a minimum will specify the priorities that will be targeted, articulate a vision for activities to address needs, describe infrastructure needed to select and implement interventions, identify resources and training requirements, include plans for sustaining the infrastructure and services, and identify milestones and outcomes against which to gauge performance. Strategic plan development is Step 3 of the SPF.
Subrecipients are the entities (usually community-based organizations, schools, or coalitions) that receive funds from the grantee and carry out SPF‑Rx activities or prevention interventions.
Sustainability is the process through which a prevention system becomes a norm and is integrated into ongoing operations. Sustainability is vital to ensuring that prevention values and processes are firmly established, that partnerships are strengthened, and that financial and other resources are secured over the long term.
Section 1: Administrative Survey
[GRANTEES SKIP TO QUESTION 7 AND COMPLETE TARGETED POPULATIONS AND OUTCOMES SUBSECTION]
This section asks questions that describe your subrecipient organization. Your subrecipient organization should be identified as the entity that is carrying out the activities/interventions of the SPF‑Rx program.
Organization Type (Subrecipients only)
Subrecipient Name (System prefill) (locked)
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1. What type of organization would you say you are? You should identify your organization as the entity that will be carrying out the activities of the SPF‑Rx program. (Select the one response that best describes your organization.) B, F
We are a community coalition. (If selected, you will skip Question 2.)
Local public health/mental health government agency responsible for substance abuse prevention
Local health/mental health care service provider or facility (e.g., local hospital, community mental health center)
Youth-focused local grassroots or community-based service or advocacy organization (e.g., local chapter of Students Against Destructive Decisions [SADD], local youth councils)
Non-youth-focused, local grassroots or community-based service or advocacy organization (e.g., substance abuse prevention organizations, YMCAs)
Faith-based organization
School or school district
Law enforcement organization
College or university
Tribal entity or organization
Other government agency, not listed above
Other nonprofit organization, not listed above
Other (Describe.)
2. Are you partnering with a community coalition (an existing group that brings together diverse organizations and individuals to collaborate on shared prevention goals)? By partnering, we mean that you have a formal relationship that is documented with a memorandum of understanding or similar agreement and/or that you provide SPF‑Rx funding. (Select one response.) B, F
Yes
No
PFS Funding History (Subrecipients only)
3. Has your subrecipient organization (i.e., entity that will be carrying out the activities of the SPF‑Rx) received SPF SIG or PFS funding? (Select one response.)B
Yes, SPF SIG only (If selected, you will skip Question 4.)
Yes, PFS only (If selected, you will skip Question 4.)
Yes, both SPF SIG and PFS (If selected, you will skip Question 4.)
No
Don’t know
4. Has your subrecipient organization (i.e., entity that will be carrying out the activities of the SPF‑Rx) been part of a coalition or group or organizations that received SPF SIG or PFS funding in the past? (Select one response.)B
Section 2: Strategic Prevention Framework
This section asks for information related to the Strategic Prevention Framework steps. You will be asked to describe your activities related to the following steps:
Needs, population of focus, and resources assessments;
Capacity building and sustainability;
Prevention intervention implementation; and
Monitoring and evaluation.
Section 2A. Needs, Population of Focus, and Resources Assessments
[GRANTEES SKIP TO QUESTION 7, POPULATION OF FOCUS AND OUTCOMES]
Needs Assessment (Subrecipients only)
This section collects information on organizational and community needs and resources assessments you conducted during this reporting period. You are asked whether or not the needs and resources of your organization and the community have been assessed.
In this section, please also describe any data you have available and the data you used to conduct your needs and resources assessment. This section also asks about the consumption patterns, consequences, intervening variables, and populations you identified to target for your SPF‑Rx activities. Finally, this section includes questions about any policies that have been developed that address health disparities.
5. Has your organization completed an assessment of community needs and resources during the past Federal fiscal year? A community needs and resources assessment examines needs external to the organization and includes community readiness, rates of substance use, prevention resources (e.g., trained intervention implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.E
Yes
No
Data Sources (Subrecipients only)
This set of questions asks about the availability of community-level prescription drug-related data for data-driven planning (e.g., needs assessments, identifying priority issues and intervening variables to target, performance monitoring). We want you to focus on local-level data that are available to your subrecipient community.
Under each of the categories Consumption, Consequence, and Intervening Variables, list the data sources, including local surveys and administrative data collection systems that are currently available for your subrecipient community.
6. For each of the types of data listed below, check the boxes to indicate (a) whether or not you have access to the data at the community level (or closest available substate area), and (b) whether you used the data to conduct your community needs and resources assessment. (Note that the geographic unit available to your community might vary depending on the data source; for example, opioid mortality or PDMP data may be available at the county or district level, but a subrecipient could cover a smaller geographic area.)E (autofill once completed initially)
Data Type |
Have access to community-level data |
The data were used for needs assessment |
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Yes |
No |
Yes |
No |
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Consumption |
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6.1. Prescription drug misuse in the past 30 days or past year |
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6.2. Prescription painkiller misuse in the past 30 days or past year |
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6.3. Lifetime prescription drug misuse (ever misused) |
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6.4. Lifetime prescription painkiller misuse (ever misused) |
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6.5. Other (Describe.) _____________________________ |
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6.6. If yes to consumption data, for what geographic level? (Choose one) |
Community
County |
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Intervening Variables |
Have access to community-level data |
The data were used for needs assessment |
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Yes |
No |
Yes |
No |
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6.7. Rate of registration of physicians with prescription drug monitoring program (PDMP) |
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6.8. Use of PDMP by physicians (number of queries; percentage of physicians making queries) |
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6.9. Opioid prescribing rates (from PDMP data) |
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6.10. Rates of high dose opioid prescribing (e.g., >90MME/day or >100MME/day) |
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6.11. Rates of opioid and benzodiazepine co-prescribing |
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6.12. Rates of multiple prescriber episodes for opioid pain medication (as indicator of possible “doctor shopping”) |
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6.13. Rates of multiple pharmacy episodes for opioid pain medication |
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6.14. Other PDMP measure of opioid prescribing (Describe.) _______________________________ |
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6.15. Consumers’ perceived risk of prescription drug misuse |
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6.16. Parent/peer attitudes about prescription drug misuse |
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6.17. Communication with parents about drug use |
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6.18. Social availability (e.g., through friends or family members) |
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6.19. Physicians’ attitudes and knowledge |
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6.20. Law enforcement practices (e.g., to address diversion; having police use Narcan to prevent overdose) |
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6.21. Other (Describe.) _____________________________ |
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Consequences |
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6.22. Mortality rates due to opioid overdose |
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6.23. Emergency department visits/hospital admissions related to opioid misuse |
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6.24. If yes to emergency department or hospital admissions data (item 6.23), for what geographic level? (Choose one) |
Community
County |
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6.25. Calls to poison center related to opioid misuse |
Have access to community-level data |
The data were used for needs assessment |
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Yes |
No |
Yes |
No |
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6.26. Other (Describe.) _________________________ |
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Data Sources |
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6.27. Prescription drug monitoring program (PDMP) data |
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6.28. Geographic data related to local patterns of opioid overdoses |
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6.29. Hospital data on opioid overdose-related emergency department visits |
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6.30. Hospital data on opioid overdose-related admissions |
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6.31. Middle school survey data about prescription/pain drug misuse |
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6.32. High school survey data about prescription/pain drug misuse |
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6.33. College survey data about prescription/pain drug misuse |
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6.34. Community surveys about prescription/pain drug misuse |
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6.35. Community survey of health care providers |
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6.36. Census data for community demographics |
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6.37. Key informant interviews or focus groups |
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6.38. Public meetings or forums (e.g., town hall meetings) |
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6.39. Other (Describe.) _________________ |
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Targeted Populations and Outcomes (Both grantees and subrecipients complete)
This set of questions asks about the specific populations your community, state, tribal entity, or jurisdiction has identified for your SPF‑Rx efforts. These populations may include specific consumption patterns, consequences, risk and protective factors (intervening variables), or subpopulations. (Note: Grantees should report their overall targets for their state, jurisdiction, or tribal area) Complete at baseline and update annually if you have any changes.
7. Indicate the consumption pattern(s) you are targeting for your SPF‑Rx activities. (Select all that apply.)E (autofill once completed initially)
Have not identified a consumption pattern to target
Misuse of prescription drugs by youth age 12 to 17
Misuse of prescription pain medicine by youth age 12 to 17
Misuse of prescription drugs by young adults age 18 to 25
Misuse of prescription pain medicine by young adults age 18 to 25
Misuse of prescription drugs by all adults age 26 and over
Misuse of prescription pain medicine by all adults age 26 and over
Other consumption pattern (Describe.)
8. Indicate the consequence(s) you are targeting for your SPF‑Rx activities. (Select all that apply.)E (autofill once completed initially)
Have not identified a consequence to target
Emergency department visits or hospitalizations related to prescription drug overdose
Emergency department visits or hospitalizations related to opioid overdose
Poisoning center calls related to prescription drugs/opioid overdoses
Prescription drug-related deaths
Opioid-overdose related deaths
Motor vehicle crashes related to prescription drug or opioid misuse
Crime related to prescription drug or opioid misuse
Other consequences (Describe.)
9. Indicate the population(s) you will be focusing on for your SPF‑Rx prevention activities. In the first column, we would like to know if you have very specific groups of people you are focusing on for your prevention interventions. For example, if you are delivering a prevention intervention to all middle schools in an area, then you would select only “middle school students”; you would not have to select all the possible race/ethnicity categories that might be enrolled in the schools. If, however, you are delivering a prevention intervention specifically designed to target high-school-age Latinos, then you would select Hispanic and high school students. (Note: If you are targeting the whole community or jurisdiction, then choose that answer option [9.1], and do not check all the subpopulations.)
In the second column, check any specific subpopulation your SPF‑Rx prevention activities are focused on to reduce prescription drug misuse-related behavioral health disparities. (These categories are not mutually exclusive. Use your judgment to select all responses that describe your population of focus.)E (autofill once completed initially)
Population |
Check if you are specifically focusing on this subpopulation |
Check if this subpopulation represents your behavioral health disparities population of focus |
9.1. We are targeting community-wide or statewide population, not any specific subpopulations |
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N/A |
9.2. Males |
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9.3. Females |
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9.4. Lesbian/gay/bisexual/transgender/questioning (LGBTQ) |
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9.5. African American |
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9.6. American Indian |
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9.7. Alaska Native |
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9.8. Asian/Pacific Islander |
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9.9. Hispanic |
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9.10. White |
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9.11. Age 12–17 |
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9.12. Age 18–25 |
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9.13. Age 26 and over |
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9.14. Other age group (Describe.) ___________________ |
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9.15. Middle school students |
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9.16. High school students |
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9.17. College students |
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9.18. Parents |
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N/A |
9.19. Current or former military or military families |
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9.20. Individuals living in poverty |
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9.21. Individuals whose native language is other than English |
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9.22. Individuals with low literacy |
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9.23. Individuals with mental illness |
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9.24. Individuals with disabilities (e.g., hearing, visually, or physically impaired) |
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9.25. Physicians/health care providers/prescribers |
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N/A |
9.26. Pharmacists/dispensers |
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N/A |
9.27. Other population of focus (Describe.) _______________________________________ |
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9.28. Other population of focus (Describe.) _______________________________________ |
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9.29. Other population of focus (Describe.) _______________________________________ |
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10. Indicate the intervening variable(s) you will be targeting for SPF‑Rx prevention. (Select all that apply.)E (autofill once completed initially)
Have not yet selected an intervening variable to target
Laws related to prescription drugs
Level of enforcement
Social access to prescription drugs (e.g., through friends or family members)
Physician/prescriber registration with prescription drug monitoring program
Physician/prescriber use of prescription drug monitoring program (increased queries)
Rate of opioid prescribing
Rate of high dose (>90 MME/day) opioid prescribing
Rate of multiple prescriber episodes for opioid pain medications (or other indicators of possible “doctor shopping”)
Norms—perceived parent or peer attitudes or both (towards prescription drug misuse)
Norms—perceived peer or friend misuse of prescription drugs
Perceived risk of harm of prescription drug misuse
Perceived risk of getting caught misusing prescription drugs (e.g., by parents or law enforcement)
Family communication around prescription drug misuse
Resistance or life skills or both
Availability of prosocial activities
Other intervening variable (Describe.)
Other intervening variable (Describe.)
Other intervening variable (Describe.)
11. How would you describe the community or communities that you are targeting for your SPF‑Rx prescription drug misuse prevention activities? (Select all that apply.)E (autofill once completed initially)
Entire state/jurisdiction
Large urban area(s) (population of more than 500,000)
Smaller urban area(s) (population of 50,001 to 500,000)
Small town or urban cluster(s) (population of 2,500 to 50,000)
Rural
Other (Describe.)
[GRANTEES SKIP TO SECTION 2C PREVENTION INTERVENTION IMPLEMENTATION]
Section 2B. Capacity Building and Sustainability (Subrecipients only)
In this section, we ask you about your activities related to capacity and sustainability. Capacity refers to the quality and level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF‑Rx, capacity refers to the demonstrated ability of subrecipients to effectively implement each SPF step (i.e., assess needs, build capacity, plan, implement, and evaluate) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model. Capacity building refers to activities conducted to improve the ability of an organization or community to deliver prescription drug misuse prevention services, such as improving organizational resources, seeking and receiving relevant training and technical assistance (T/TA), building new relationships or strengthening existing relationships among groups and organizations involved in prescription drug misuse prevention, and ensuring that prevention intervention activities and outcomes continue after SPF‑Rx funding ends.
Current Capacity (Subrecipients only)
12. How would you rate the current capacity of your organization in the following areas for SPF‑Rx prevention efforts? (Note: At baseline, the questions should be answered with regard to your organization’s capacity at the time the SPF‑Rx grant was awarded.) E
How much would you agree or disagree that your organization currently has enough capacity in each of the following areas to effectively implement your SPF‑Rx prevention efforts? |
Strongly disagree |
Disagree |
Agree |
Strongly agree |
12.1. Capability and experience using the 5 SPF steps |
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12.2. Experience with the populations of focus for prescription drug misuse prevention |
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12.3. Experience working with health care providers and pharmacists for prescription drug misuse prevention |
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12.4. Experience with relevant interventions for prevention of prescription drug misuse |
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12.5. Experience collaborating with other organizations on interventions to prevent prescription drug misuse |
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12.6. Capability to use prescription drug monitoring program (PDMP) data for prevention planning and surveillance |
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12.7. Capability to use PDMP data for prevention evaluation |
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12.8. Capability to combine PDMP with other data sources (e.g., overdose data) for prevention planning |
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12.9. Staff with the right skills to effectively implement SPF‑Rx prevention efforts |
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12.10. Enough staff to effectively implement SPF‑Rx prevention efforts |
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12.11. Enough fiscal/financial resources to effectively implement SPF‑Rx prevention efforts |
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12.12. Capability to sustain the prevention efforts over time |
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Training and Technical Assistance (Subrecipients only)
13. Select the area(s) in which you needed, requested, and/or received SPF‑Rx-related guidance or training and technical assistance (T/TA) during the past Federal fiscal year. We are specifically asking about guidance and T/TA that contributed to your SPF‑Rx activities. (Select all that apply.) E
Training/technical assistance (T/TA) areas |
Needed or need T/TA in this area |
Received T/TA in this area |
13.1. Needs and resource assessment |
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13.2. Using prescription drug monitoring data for prevention assessment, planning, and monitoring |
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13.3. Using other data sources for prescription drug misuse prevention efforts |
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13.4. Opioid addiction and epidemiology, including risk and protective factors |
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13.5. Prescription drug misuse/abuse prevention |
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13.6. Strategic plan development |
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13.7. Staff, task force, or coalition member training |
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13.8. Building collaborative relationships with stakeholders and partner agencies |
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13.9. Working with medical and pharmaceutical communities to prevent prescription drug misuse |
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13.10. Working with organizations to help them establish or implement polices to reduce risk of prescription drug misuse (e.g., incorporation of national CDC prescribing guidelines into health care providers’ rules and codes) |
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13.11. Developing strategies to enhance PDMP use |
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13.12. Working with law enforcement to prevent prescription drug misuse |
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13.13. Intervention availability and selection |
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13.14. Participant recruitment |
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13.15. Intervention implementation |
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13.16. Intervention adaptation |
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13.17. Cultural competence |
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13.18. Behavioral health disparities |
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13.19. Evaluation |
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13.20. Sustainability |
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13.21. Public policy (e.g., collaborating to inform or implement policy change) |
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13.22. Social marketing/social media/public education |
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13.23. Environmental strategies to prevent prescription drug misuse |
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13.24. Strategies to increase safe storage and disposal of prescription drugs |
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13.25. Privacy issues related to data use, including HIPAA |
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13.26. Other ethical issues related to prevention work |
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13.27. Other (Describe.) __________________________________ |
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13.28. Other (Describe.) __________________________________ |
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13.29. Other (Describe.) __________________________________ |
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Development of SPF‑Rx Organizational Resources (Subrecipients only)
This section collects information on the activities you conducted to improve your SPF‑Rx organizational capacity, such as writing mission or vision statements, identifying goals and activities, training staff and collaborators, and creating an advisory board.
14. Have you conducted activities that produced gains in your SPF‑Rx organizational resources or capabilities related to SPF‑Rx during the past year? These could include such activities as identifying organizational goals, improving staff and resources, and coordinating data collection. (Select one response.)E
Yes
No (If selected, you will skip Question 15.)
15. Indicate the activity or activities you conducted during the past Federal fiscal year that produced gains in your SPF‑Rx organizational resources. (Select all that apply.)E
Did not engage in activities that increased organizational resources during this reporting period
Wrote or revised organizational or coalition mission or vision statement
Created an advisory board
Identified coalition leaders (if there is a coalition)
Recruited new community partners
Identified key organizational or coalition activities and goals
Increased staffing
Trained staff or coalition members on use of prescription drug monitoring program data for prevention
Trained staff in other areas related to prescription drug misuse prevention
Trained coalition members
Improved cultural competence for SPF‑Rx populations of focus
Secured additional funding
Secured physical space
Established a dedicated community assessment team
Modified or developed data systems (for prescription drug prevention efforts
Other: (Describe.)
16. Below is a list of funding sources that could be used to support prevention of prescription drug misuse. Please check the box in the column next to the funding source if your organization has used funding from this source to support SPF‑Rx-related activities during the past Federal fiscal year. Consult with your SPF‑Rx grantee if you are unsure of some of these funding sources. Do not include funding received by other organizations in your coalition or group, unless those funds are used for SPF‑Rx-related activities.E
Source of funding/resources |
Do you use any funding from this source to support SPF‑Rx-related activities? |
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YES |
NO |
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16.1. SPF-Partnerships for Success (PFS) (SAMHSA) |
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16.2. Substance Abuse Prevention and Treatment Block Grant (SAMHSA) |
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16.3. SAMHSA Prescription Drug Overdose Prevention grant |
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16.4. SAMHSA Medical-Assisted Treatment (MAT) |
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16.5. CDC Prevention for States (PfS) |
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16.6. CDC Data-Driven Prevention Initiative (DDPI) |
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16.7. BJA Harold Rogers PDMP |
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16.8. SAMHSA Minority HIV/AIDS Initiative |
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16.9. HRSA Rural Opioid Overdose Reversal (ROOR) |
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16.10. Drug-Free Communities (DFC) grant |
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16.11. Medicaid (Federal, state, local) |
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16.12. Other Federal funds (Describe.) _______________________________________ |
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16.13. Other state/tribal/jurisdiction funds (Describe.) _______________________________________ |
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16.14. Other local government funds (Describe.) _______________________________________ |
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16.15. Foundations/nonprofit organizations |
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16.16. Corporate/business entities |
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16.17. Individual donations/funding from fundraising events |
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16.18. Other (Specify.) _______________________________________ |
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Relationship Building (Subrecipients only)
This section collects information on partners you identified in your proposal (or workplan?) to join your SPF‑Rx partnership or participate in planning and prevention intervention activities.
17. Have you identified key stakeholders, partners, and partner organizations to participate in your SPF‑Rx planning and prevention intervention activities? This includes coalition members if you are working with a coalition. (Select one response.)E
Yes
No (If selected, you will skip Question 18.)
18. Provide more information on the key stakeholders, partners, and partner organizations that participate in your organization’s SPF‑Rx activities. This may include a combination of individuals and organizations. “Active” refers to stakeholders/partners who demonstrated support or participation in your activities and interventions during the past year.E (autofill column 2 after initially completed)
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Sector
For each sector below, how many of these key stakeholder or partner members were “active” during the past year?
What was the average level of involvement for the members of this sector in your SPF‑Rx activities during the past year?
(Mark only if # active partners >0)
Low
Medium
High
18.1. Physicians/health care providers or health care organizations (excluding hospitals/hospital staff)
18.2. Hospital medical staff or hospital organization
18.3. Dentists or dental organizations
18.4. Pharmacists/pharmacy organizations
18.5. Substance abuse prevention professionals/organizations
18.6. Substance abuse treatment professionals/organizations
18.7. Mental health professionals/agencies
18.8. Insurance professionals or organizations
18.9. Youth groups/representatives
18.10. Schools/school districts
18.11. Colleges and universities
18.12. Other youth-serving professionals/organizations
18.13. Parents/family/caregiver groups
18.14. Tribal leaders or elders
18.15. Business community
18.16. Workers compensation programs
18.17. Media (radio/TV stations; newspapers)
18.18. Clergy/faith-based organizations
18.19. Civic or volunteer organizations/professionals
18.20. Organizations/individuals serving LGBTQ population
18.21. Military professionals/agencies
18.22. Law enforcement professionals/agencies
18.23. Courts/judiciary system professionals/agencies
18.24. Other state, local, or tribal government agencies
18.25. Other organizations/sectors (Describe.) _____________
18.26. Other organizations/sectors (Describe.) _____________
18.27. Other organizations/sectors (Describe.) _____________
Data Infrastructure (Subrecipients only)
19. Did your community have access to community-level PDMP data/reports for prevention planning prior to the SPF‑Rx grant?B (Baseline)
Yes, we had access, but did not normally use PDMP data for prevention
Yes, we had access and normally used PDMP data for prevention planning
No, we did not have access to PDMP data
20. During the past Federal fiscal year, approximately how often did you receive updated PDMP data/reports for your SPF‑Rx target communities (or the closest available substate area)? (Select one)E
Did not receive any PDMP data/reports in the past fiscal year
Once
Semi-annually (twice per year)
Quarterly
Every other month
Monthly
Other (Specify.)
21.1. For what geographic area are PDMP data/reports available to you? (Select all that apply.)E
PDMP data are not available to us yet
Community
County
District
State
Other (Specify.) _________________________________________________________
21.2. Are privacy or HIPAA concerns a major barrier to receiving community-level PDMP reports?E (update annually only if it changes)
Yes
No
22. How has your access to and use of community-level PDMP data/reports as part of your SPF‑Rx effort affected your local prevention efforts? (Select all that apply.) F (Final)
We did not get access to any community-level PDMP data/reports during the grant
We had access to community-level PDMP data/reports, but we were not able to use them
PDMP data did not significantly change our prevention approach
PDMP data changed our understanding of the problem
PDMP data guided local prevention strategies in new directions
PDMP data enabled us to better monitor risky prescribing and dispensing patterns
PDMP data informed enforcement efforts in new ways
Other (Describe.)
23. During this reporting period, how have you worked to develop or enhance data infrastructure needed for data-driven needs assessment, planning, monitoring, and evaluation? (Select all that apply.)E
Not applicable; no work was done to enhance data infrastructure during this reporting period
Developed or enhanced procedures for accessing prescription drug monitoring program (PDMP) data/reports
Developed or enhanced procedures for accessing hospital data
Developed or enhanced procedures for accessing data from other agencies (e.g., vital statistics, Census)
Developed or implemented a community-level survey data collection effort
Developed or implemented a community-led qualitative data collection effort (e.g., interviews, focus groups)
Created or enhanced a local database to house community surveillance data
Developed procedures for participation in a state/tribal/jurisdiction database
Enhanced skills or expertise of local stakeholders to use PDMP data…
How did you enhance skills or expertise of local stakeholders to use PDMP data? (Check all that apply)
For development of local strategies and interventions (e.g., with medical and pharmacy communities)
For surveillance and performance monitoring
Other (Describe.) ________________________________________________
Developed procedures for utilizing PDMP data provided by the state/tribal entity/jurisdiction
Developed or enhanced standardized prescription drug/opioid misuse surveillance reports
Other (Describe.) ___________________________________________________________
Sustainability (Subrecipients only)
This section asks about things you have done to ensure that SPF‑Rx related prevention intervention activities and outcomes continue once SPF‑Rx funding ends. These efforts might focus on ensuring continued funding, structures, networks, partnerships, leadership, and resources.
24. During the past Federal fiscal year, how have you worked to ensure that prescription drug misuse prevention intervention activities and outcomes continue after SPF‑Rx funding has ended? (Select all that apply.)E
Not applicable; no work was done in the past year to ensure that prescription drug misuse prevention intervention activities and outcomes continue after SPF‑Rx funding has ended.
Leveraged, redirected, or realigned other funding sources or in-kind resources (e.g., used the success of the SPF‑Rx efforts to secure other funds)
Worked to ensure that prescription drug misuse prevention intervention activities are incorporated into the missions/goals and activities of other organizations (e.g., medical boards, local pharmacies, school districts, law enforcement agency)
Worked to ensure that prescription drug misuse prevention staff positions are integrated into other organizations (e.g., health departments, school districts, community agencies)
Worked to gain formal adoption of prescription drug misuse prevention intervention activities into other organizations’ practices (e.g., health care provider organizations, pharmacies, medical school curriculum, school district curriculum, organizational policy change)
Worked to inform, help implement, or provide education related to new laws, policies, or regulations to guarantee the continuation of prescription drug misuse prevention intervention activities or outcomes
Worked on developing a prescription drug misuse partnership structure that will continue to function beyond the end of the SPF‑Rx grant period
Worked to create sustainable data infrastructure and staffing to continue to monitor PDMP and other surveillance data after SPF‑Rx grant ends
Other (Describe.)
Section 2C. Prevention Intervention Implementation (Both grantees and subrecipients complete)
This section collects information about the prevention interventions you selected for implementation in your service area. A prevention intervention is an activity or set of activities to which a group or community is exposed to in order to change their behavior. For SPF‑Rx, these activities should aim to prevent or lower the rate of prescription drug misuse and abuse and related problems. Interventions include activities related to community-based processes (e.g., holding meetings or training with community members, reallocating funds for prevention in the community, reorganizing local agencies and organizations to address prescription drug misuse prevention), prevention education, alternative activities, problem identification and referral, environmental strategies (e.g., training of environmental influencers, policy change, enforcement), and information dissemination and other communication activities (e.g., raising community awareness, conducting media campaigns). Refer to the Annual Implementation Instrument manual for more information.
25. Did you or your community partners deliver any SPF‑Rx related prevention interventions during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Questions 26–124.)
Implemented Prevention Interventions
26. Name all the prevention interventions you or your partners delivered during this reporting period as part of your SPF‑Rx efforts. Refer to the Annual Implementation Instrument Manual before you complete the information in this section. That document will help you understand what to report as a prevention intervention in this section; which activities you should list as separate service types related to that intervention; and how to determine the appropriate CSAP strategy type, Institute of Medicine category, and so on.E (autofill for interventions previously reported, except for active/inactive status)
You will need to complete a separate implementation information sub-form for each prevention intervention-service type you name below that was active during the past year. The CSAP strategy type will determine a subset of questions you must complete for the prevention intervention and service type.
26a. Intervention name |
26b. Service type |
26c. Service type name |
26d. Date started |
26e. CSAP strategy type |
26f. Institute of Medicine (IOM) category |
26g. Intervention targets |
26h. Status |
26i. Date completed or discontinued |
From the drop-down menu, select the name of each prevention intervention you are implementing, or select “other” and write in the name. To review a full list of the intervention names, refer to the Intervention Name List. |
From the drop-down menu, select the service type for each major set of services or activities you are implementing under this prevention intervention, or select “other” and write in the name. Many strategies may consist of only one service type. |
Write in the name of the specific set of services or activities that you implemented as part of your intervention if this name differs from the service type label |
Date you began funding this intervention-service type through your SPF‑Rx initiative (MM/YYYY) |
Select the CSAP strategy type that best describes this intervention-service type:
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Select the IOM category for this intervention-service type:
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Select the option that best describes the targets of this intervention-service type:
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Check whether the intervention-service type was Active, Inactive, Completed, or Discontinued during the past year |
For intervention-service types completed or discontinued during the past year, indicate the date completed or discontinued (MM/YYYY) |
Sample Table:
26a. Intervention name |
26b. Service type |
26c. Service type name |
26d. Date started |
26e. CSAP strategy type |
26f. Institute of Medicine (IOM) category |
26g. Intervention targets |
26h. Status |
26i. Date completed or discontinued |
Train/educate health care providers on safe prescribing/CDC guidelines |
Training/ educating environmental influencers |
Training/ educating environmental influencers |
03/2013 |
Environmental |
Universal indirect |
Medical community |
Complete |
09/2016 |
Media campaign—Count it! Lock it! Drop it! |
Media campaigns |
Media campaigns |
05/2016 |
Information dissemination |
Universal direct |
Whole communities |
Incomplete |
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Policy, reg, or law change/ implementation—prescriber opioid training |
Change/ implement new public policies, regs, or laws |
Change/ implement new public policies, regs, or laws |
10/2013 |
Environmental |
Universal indirect |
Medical community |
Complete Policy instituted: Yes |
12/2016 |
Prescription Drug Safe Storage and/or Disposal—Drop Box Installation |
Prescription drug safe storage and/or disposal
|
Prescription drug safe storage and/or disposal |
01/2014 |
Environmental |
Universal indirect |
Whole communities |
Complete |
01/2016 |
Prevention Intervention and Service Type Information
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Intervention questions
27.1. What specific consumption pattern(s) or consequence(s) (or both) are the prevention intervention intended to target? (Select all that apply.)E (autofill after first completed)
Misuse of prescription drugs/pain medication by youth age 12 to 17
Misuse of prescription drugs/pain medication by young adults age 18 to 25
Misuse of prescription drugs/pain medication by young adults age 26 and over
Prescription drug/opioid-related deaths
Emergency department visits or hospitalizations related to prescription drug/opioid overdose
Poisoning center calls related to prescription drug/opioid overdoses
Motor vehicle crashes related to prescription drug or opioid misuse
Crime related to prescription drug or opioid misuse
Other consumption pattern or consequence (Describe.)
Other consumption pattern or consequence (Describe.)
27.2. What specific intervening variable(s) is the prevention intervention intended to target? (Select all that apply.)E (autofill after first completed)
Have not yet selected an intervening variable to target
Laws or regulations related to PDMP data (access, use, timeliness, or quality)
Laws or policies related to prescriber or dispenser training or practices
Other laws or policies related to prescription drugs/pain medications
Rate of registration of physicians with prescription drug monitoring program (PDMP)
Use of PDMP by physicians (number of queries; % of physicians making queries)
Opioid prescribing rates (from PDMP data)
Rates of high dose opioid prescribing (>90MME/day)
Rates of multiple prescriber episodes for opioid pain medication (as indicator of possible “doctor shopping”)
Rates of multiple pharmacy episodes for opioid pain medication
Law enforcement practices
Social access or availability (e.g., through family and friends)
Norms—perceived parent or peer attitudes or both
Norms—perceived peer use
Consumers’ perceived risk of harm of prescription drug misuse
Consumers’ perceived risk of getting caught
Family communication around prescription drug misuse
Resistance or life skills or both (continued)
Availability of prosocial activities
Other intervening variable (Describe.)
Other intervening variable (Describe.)
Other intervening variable (Describe.)
28.1. To your knowledge, is this intervention an evidence-based program, policy, or practice? Evidence Based Practices, Policies, and Programs: EBPPPs are defined as interventions that come from a Federal Registry, were reported as effective for your target substance in a published scientific journal article, were based on a documented theory of change, or were deemed effective by a panel of experts (Select one response.)E (autofill after first completed)
Yes
No
Don’t know
28.2. How did you select your intervention? (Select all that apply.)E (autofill after first completed)
Inclusion in a Federal registry of evidence-based interventions
Found to be effective (on the primary targeted outcome) in a published, scientific journal
Similar in content and structure to interventions that appear in registries or peer-reviewed literature
Supported by documentation of effective implementation multiple times in the past (showing consistent pattern of positive effects)
Reviewed by a panel of informed experts including qualified prevention researchers, local prevention practitioners, and key community leaders (e.g., law enforcement and education representatives, elders within indigenous cultures)
Recommended by evidence-based practice workgroup (EPBW)
Appeared on a list of recommended promising or evidence-based programs, policies, and practices provided by our state, tribal entity, or jurisdiction
Recommended by the SPF‑Rx grantee (state, tribe, or jurisdiction) but not on a formal list of promising or evidence-based programs, policies, and practices
Is based on guidelines, protocols, standards, or preferred practice patterns that have been proven to lead to effective prevention outcomes
Based on a theory of change that is documented in a clear logic or conceptual model
Other (Describe.)
29. Have you renamed the existing promising or evidence-based program, policy, or practice to implement it in your community? (Select one response.) E (autofill after first completed)
Yes (Provide the original name.)
No
30. Which of the following best describes the implementation history of this prevention intervention in your community? (Select one response.) E (autofill after first completed)
Not implemented in the community before SPF‑Rx funding
Continuation of a SPF-SIG or PFS prevention intervention
Continuation of a non-SPF-SIG and non-PFS prevention intervention
31. Were any adaptations made to address the cultural appropriateness of the prevention intervention strategy for a particular group (e.g., modifying the language or slang used, modifying the examples, including visuals of individuals who represent your population of focus) in the past Federal fiscal year? (Select one response.)E
Yes (Describe.)
No
Service type questions
Name of Prevention Intervention: _________________________________ (autofill from Question 26)
Service Type: ___________________________________________ (autofill from Question 26)
32. For Questions 32.1–32.5, indicate the locations and population of focus being served by this prevention intervention-service type. If you are implementing in separate settings (e.g., schools, workplaces), list each setting separately. (Note: If you are implementing a media campaign that reaches the whole county, you may enter “county-wide” for location (Question 32.1).)
Use one line to describe each location served by the intervention-service type. Other than estimated population of focus (Question 32.5), you need to complete only those categories that are appropriate for this prevention intervention-service type and community served.E (autofill after first completed)
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32.1. Location (e.g., school name, business, community center) |
32.2. City/town |
32.3. County/ parish |
32.4. Population of focus description (Describe; 500-character limit) |
32.5. What is the estimated population of focus number intended to reach within the area described?a |
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aThe Population of Focus of the intervention strategy is likely smaller than the total population in the community. For example, if 10,000 individuals live in the area (total population), but only 3,000 of those are in the target 12- to 20-year-old age group for this prevention intervention strategy, your estimated target population is 3,000. If your target population for this prevention intervention strategy is more specific (e.g., Hispanic high school students or non-college youth age 18 to 20), your population of focus number would be even smaller (e.g., 200). Report your population of focus size as accurately as possible.
Community-Based Processes Sub-Form
Name of Prevention Intervention: _________________________________ E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
For this sub-form, we are interested in community-based intervention-service type activities that you expect will enhance the ability of the community or prevention system to influence substance use and abuse. Community-based processes you describe here might include holding more specific meetings with or training key stakeholders and partners or other community members and organizations; developing prevention provider networks; reorganizing local agencies; reallocating community prevention funds; or formally changing how local organizations work together to prevent substance abuse.
Activities related to more general capacity building (e.g., training prevention staff, building stakeholder or partner relationships) or the general functioning of your organization (e.g., coalition meetings) should not be included here and are better described in the capacity-building section earlier in this instrument. Also, you should categorize trainings of environmental influencers such as beverage servers or physicians/pharmacists as environmental strategies for CSAP strategy type and complete that sub-form instead.
34. For this intervention-service type, did you do any work related to community-based processes (e.g., stakeholder/partner meetings, T/TA for community, reorganization of local agencies, or reallocation of community funds for prescription misuse prevention) during the past year? E
Yes
No (If selected, you will automatically proceed to the end of this sub-form.)
35. Indicate the number of stakeholder/partner meetings you held during the past year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
meetings (If none, enter ‘0.’)
36. Indicate the number of stakeholders/partners you trained during the past year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
stakeholders/partners trained (If none, enter “0.”)
37. Indicate the number of community members, other than stakeholders/partners, you trained during the past year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
community members trained (If none, enter “0.”)
38. Indicate the number of community organizations to whom you provided training or technical assistance during the past year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
community organizations (If none, enter “0.”)
39. Did you develop a prescription drug misuse prevention provider network during the past year for this intervention-service type? For example, you may have established a prescriber and dispenser group that meets regularly. (Select one response.)E
Yes
No, we do not yet have a network
No, a network was already in place
40. For this intervention-service type, during the past year, did you help with reorganizing agencies to promote efficiency in delivering prescription drug misuse prevention services? (Select one response.)E
Yes
No
41. For this intervention-service type, during the past year, did you reallocate other (non-SPF‑Rx) sources of funding to help support the goals of your SPF‑Rx effort? (Select one response.)E
Yes
No
42. For this intervention-service type, during the past year, did you formally change the ways organizations work together to prevent prescription drug misuse —for example, by documenting specific policies or practices for working together? (Select one response.)E
Yes
No
43. For this intervention-service type, did you conduct other community activities during the past year? (Select one response.)E
Yes (Describe.)
No
44. Estimate the total number of individuals in your population of focus who were indirectly reached or affected by this community-based process intervention-service type during the past Federal fiscal year. Approximately how many individuals were affected by the results of this intervention-service type? (Note: Because this is a population-based intervention, you are asked to estimate the number of people reached. In most cases, this number should not exceed the sum of the populations of focus you reported in item 32.7 for this service type. For direct service interventions, such as prevention education, you will be asked to report the number directly served.)E
(Prepopulate: Sum of reported population of focus in item 32.7 for this service type: ___________________)
Enter the estimated number of individuals in the population of focus reached or affected by this intervention-service type. (If none, enter “0”—you will automatically proceed to the end of this sub-form.) _____________________
(Questions 45–48 have been deleted.)
Prevention Education Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
This sub-form should focus on prevention education intervention-service types that involve two-way communication between an educator or facilitator and participants. Prevention education intervention-service type activities focus on improving critical life and social skills, such as decision making, refusal, critical analysis of media messages, and judgment. These activities include classroom sessions for all ages, parenting and family management classes, and peer leader programs. Prevention education typically uses curriculum-based materials.
The activities included under prevention education should focus on more than just providing information to participants, such as through a community presentation or disseminating brochures or other materials; these types of activities should be categorized as and described under information dissemination. Please categorize trainings of environmental influencers such as physicians/pharmacists as environmental strategies for CSAP strategy type and complete that sub-form instead.
49. Indicate the type(s) of participants served by this prevention education intervention during the past Federal fiscal year.E
49.1. Age group(s) targeted for service during the past year: (Select all that apply.)
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.)
49.2. Population type(s) targeted for service during the past year: (Select all that apply.)
Middle school students
High school students
College students
Parents
Employees (i.e., recipients of a workplace substance abuse prevention program)
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
50. In the table below, list each separate location where you implemented this prevention education intervention and then indicate how many groups of participants started the prevention education intervention during the past year and how many groups completed the prevention education intervention during the past year. Do not include groups who started and completed in previous reporting periods. Count each group in the location separately (e.g., count each classroom in each school). The number of groups should be written as a whole number (e.g., 4).E
50.1. Location (e.g., Wade Middle School) |
50.2. Number of groups started in the past year |
50.3. Number of groups completed in the past year |
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51.1. What was the average number of sessions provided for each group of participants in the prevention education intervention during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
___ sessions
51.2. What was the average length of the individual sessions, in hours, during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
___ hours
52. How many total participants were served by this prevention education intervention during the past year? This response should be written as a whole number (e.g., 4).E
___ participants
(If
none, enter “0”—you will automatically proceed to
the end of this sub-form.)
53. Of the total number of participants served by this prevention education intervention during the past year (reported in Question 52), indicate how many were male and how many were female. The number of females, males, transgender, other, and unknown should add up to the total of participants reported in Question 52. This response should be written as a whole number (e.g., 4) and not as a percentage.E
53.1. Females: _____________
53.2. Males: ______________
53.3. Transgender: ______________
53.4. Other: _____________________________ (Specify: _____________________)
53.5. Gender unknown: ______________
54. Of the total number of participants served by this prevention education intervention during the past year (reported in Question 52), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 52. This response should be written as a whole number (e.g., 4) and not as a percentage.E
54.1. Children age 0 to 11: _____________
54.2. Youth age 12 to 17: _____________
54.3. Young adults age 18 to 25: _____________
54.4. Adults age 26 and older: _____________
54.5. Age unknown: ___________
55. Of the total number of participants served by this prevention education intervention during the past year (reported in Question 52), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 52. This response should be written as a whole number (e.g., 4) and not as a percentage.E
55.1. American Indian or Alaska Native: _____________
55.2. Black or African American: _____________
55.3. White: _____________
55.4. Asian: _____________
55.5. Native Hawaiian or Other Pacific Islander: ______________
55.6. Multiracial: ___________
55.7. Other: _____________
55.8. Race unknown: ___________
56. Of the total number of participants served by this prevention education intervention during the past year (reported in Question 52), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 52. This response should be written as a whole number (e.g., 4) and not as a percentage.E
56.1. Hispanic, Latino/a, or of Spanish origin: ____________
56.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
56.3. Hispanic ethnicity unknown: ____________
Alternative Drug-Free Activities Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
This sub-form should focus on alternative drug-free activities, including recognition and drug-free leisure activities implemented as a means of halting or reducing substance abuse. Alternative programs include a wide range of activities that appeal to children and youth: athletics, art, music, movies, and community service projects. Related intervention-service type activities often provide youth who live in high-risk communities with safe alternative environments and opportunities to develop relationships with non-substance-using peers.
57. Indicate the type(s) of participants served by this alternative drug-free activity during the past Federal fiscal year.E
57.1. Age group(s) targeted for service during the past year: (Select all that apply.)
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.)
57.2. Population type(s) targeted for service during the past year: (Select all that apply.)
Middle school students
High school students
College students
Parents
Employees (i.e., recipients of a workplace substance abuse prevention program)
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
58. Are the alternative activities targeted at identifiable participants (as in student clubs, mentoring), or with events for populations as a whole (as in drug-free events, festivals/fairs, drop-in activities? (Select all that apply.)E
Identifiable participants (If selected, you will complete Questions 59–61.)
Populations as a whole (If selected, you will complete Questions 62–63.)
Questions for alternative activities targeted at identifiable participants
59. In the table below, list each separate location where you implemented this alternative drug-free activity and then indicate how many groups of participants started this alternative drug-free activity during the past year and how many groups completed the alternative drug-free activity during the past year. Do not include groups who started and completed in previous reporting periods. Count each group in the location separately (e.g., count each classroom in each school). The number of groups should be written as a whole number (e.g., 4).E
59.1. Location (e.g., Wade Middle School) |
59.2. Number of groups started in the past year |
59.3. Number of groups completed in the past year |
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60. What was the average number of sessions provided for each group of participants in this alternative drug-free activity during the past year? This response should be written as a whole number (e.g., 4).E
________ sessions
61. What was the total number of hours provided for each group of participants in this alternative drug-free activity during the past year? This response should be written as a whole number (e.g., 4).E
________ hours
Questions for alternative activities delivered to populations as a whole, not identifiable participants
62. What type(s) of the alternative activity events that were not targeted to identifiable participants did you implement during the past year? (Select all that apply.)E
Concert
Festival or fair
Sporting event
Picnic
Drop-in activity
Web-based gathering
Other (Describe.)
63. How many separate alternative activity events that were not targeted to identifiable participants were conducted during the past year? This response should be written as a whole number (e.g., 4).E
________ events
64. How many total participants were served by this alternative drug-free activity during the past year? This response should be written as a whole number (e.g., 4).E
________ participants
(If
none, enter “0”—you will automatically proceed to
the end of this sub-form.)
65. Of the total number of participants served by this alternative drug-free activity during the past year (reported in Question 64), indicate how many were male and how many were female. The number of females, males, transgender, other, and unknown should add up to the total number of participants reported in Question 64. This response should be written as a whole number (e.g., 4) and not as a percentage.E
65.1. Females: _____________
65.2. Males: ______________
65.3. Transgender: ____________________
65.4. Other: ___________________________ (Specify: _______________________)
65.5. Gender unknown: _______________
66. Of the total number of participants served by this alternative drug-free activity during the past year (reported in Question 64), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 64. This response should be written as a whole number (e.g., 4) and not as a percentage.E
66.1. Children age 0 to 11: _____________
66.2. Youth age 12 to 17: _____________
66.3. Young adults age 18 to 25: _____________
66.4. Adults age 26 and older: _____________
66.5. Age unknown: _____________
67. Of the total number of participants served by this alternative drug-free activity during the past year (reported in Question 64), indicate how many were in each of the racial groups listed below. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 64. This response should be written as a whole number (e.g., 4) and not as a percentage.E
67.1. American Indian or Alaska Native: _____________
67.2. Black or African American: _____________
67.3. White: _____________
67.4. Asian: _____________
67.5. Native Hawaiian or Other Pacific Islander: ______________
67.6. Multiracial: ___________
67.7. Other: _____________
67.8. Race unknown: ___________
68. Of the total number of participants served by this alternative drug-free activity during the past year (reported in Question 64), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 64. This response should be written as a whole number (e.g., 4) and not as a percentage.E
68.1. Hispanic, Latino/a, or of Spanish origin: ____________
68.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
68.3. Hispanic ethnicity unknown: ____________
Problem Identification and Referral Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
This sub-form should focus on problem identification and referral activities that aim to identify those who have engaged in illegal or age-inappropriate use of alcohol, first use of illicit drugs, and nonmedical use of prescription drugs to reverse or stop the behavior. It may include screening programs to identify individuals in need of services, including online screening and feedback programs or employee and student assistance programs.
69. Indicate the type(s) of participants served by this Problem Identification and Referral prevention intervention during the past Federal fiscal year.E
69.1. Age group(s) targeted for service during the past year: (Select all that apply.)
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.)
69.2. Population type(s) targeted for service during the past year: (Select all that apply.)
Middle school students
High school students
College students
Parents
Health care providers
Employees (i.e., recipients of a workplace substance abuse prevention program)
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
70. Where did this problem identification and referral activity take place during the past Federal fiscal year? (Select all that apply.)E
School
Health care facilities
Jails or prisons
Courts
Workplace or workplace program
Other (Describe.)
71. At how many different places did this problem identification and referral activity occur during the past year? How many different cycles of this activity did you implement at each location? List each separate organization or location where problem identification and referral activities occurred as a separate place (e.g., list each separate school, health care facility, and so on). Then indicate the number of cycles in which you implemented this activity at each location, if applicable. If the activity is ongoing and does not occur in distinct cycles, indicate not applicable (NA).E
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72. What type(s) of services were individuals referred to during the past year? (Select all that apply.)E
Substance abuse treatment
Mental health treatment
Substance abuse prevention activities
Housing services
After-school activities
Transportation
Day care or adult care services
Health care
Other (Describe.)
73. What was the total number of individuals served by the problem identification and referral services provided during the past year? This response should be written as a whole number (e.g., 4).E
________ individuals
(If
none, enter “0”—you will automatically proceed to
the end of this sub-form.)
Environmental Strategies Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
This sub-form should focus on environmental strategies that establish or change community conditions to influence substance misuse and abuse. Approaches may center on policy, regulatory, or legal changes or implementation; efforts to maximize enforcement of laws or policies related to prescription drugs; organizational-level policy change; or training of those able to directly influence environmental conditions, such as health care professionals, pharmacists, and law enforcement.
Note that you should report all media and communication campaigns under information dissemination and communication strategies and all parent education programs under prevention education. Note that if you conduct an information dissemination campaign to promote use of existing prescription drug drop boxes, you would report that in the information dissemination sub-form. In this section, you would report on the installation of new drop boxes.
Throughout this section, refer to your organization or partners with your organization. For example, if you worked with the police department on diversion, you would report it on this form.
In the remainder of this sub-form, you will be asked to report on environmental strategy types that are relevant to your SPF‑Rx activities. The environmental strategy intervention-service type you are currently describing may fit into one or more of the following types, and you will find related questions throughout this sub-form. If you don’t see questions specifically related to this environmental strategy, you will be able to describe other types of environmental activities at the end of this sub-form.
Training and education of environmental influencers—people who are in positions to affect prescription drug misuse and abuse through medication prescribing and dispensing practices, communication, policy, enforcement, and so on (e.g., health care providers, pharmacists, insurers, law enforcement officers, school employees);
Policy, regulation, or law enactment or implementation (e.g., changing, implementing, or strengthening the implementation of new laws related to safe opioid prescribing practices or health care provider registration and use of PDMP; changing opioid training requirements for physician credentialing or licensure; and changes to organizational codes, rules, or policies);
Enforcement (e.g., collaborating with law enforcement or medical boards to develop policies to address diversion or enforcement of pain clinic regulations); and
Other environmental strategies, such as expansion of prescription drug drop boxes in pharmacies and distribution of home lock boxes for prescription drugs.
Training and educating environmental influencers
In this section, report strategies that include providing training and individual education for those in positions to affect prescription drug misuse and abuse through policy, prescribing and dispensing practices, enforcement, communication, and so on (e.g., health care providers, pharmacists, law enforcement officers, school employees). Include only training and individual education related to the specific environmental strategy on which you are reporting in this sub-form. Do not include training conducted for other environmental strategies that you have listed as separate environmental strategies.
78. Did this environmental strategy include training or individual education (e.g., “detailing”) with environmental Influencers—those in positions to affect prescription drug misuse through policy, enforcement, communication, and so on (e.g., health care providers, pharmacists, law enforcement officers, school employees)? (Select all that apply.)E
Yes, group training of environmental influencers
Yes, individual education of environmental influencers (If selected, you will skip Questions 80–81.2.)
No (If selected, you will skip Questions 79–82.)
79. To which types of environmental influencers did you provide training or individual education to affect prescription drug misuse through policy, enforcement, communication, and so on during the past year? (Select all that apply.)E (autofill after first completed)
Health care providers/medical community
Dentists/dental community
Pharmacists/pharmacy community
Insurers
School employees or administrators
Law enforcement
Other policymakers such as elected officials
Tribal leaders or elders
Business owners or employees
Service or civic organization employees or administrators
Media members
Military personnel or veterans’ organizations
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
80.1. How many groups of participants started the training of environmental influencers during the past year? Do not include groups counted in previous reporting periods. This response should be written as a whole number (e.g., 4).E
________ groups started
80.2. How many groups of participants completed the training of environmental influencers during the past year? Include groups that started and completed in this reporting period as well as groups that started in prior reporting periods but completed in this one. This response should be written as a whole number (e.g., 4).E
________ groups completed
81.1. How many training sessions were conducted for each group of environmental influencers during the past year? This response should be written as a whole number (e.g., 4).E
________ sessions
81.2. What was the average length of the individual training sessions, in hours, during the past year? This response should be written as a whole number (e.g., 4).E
________ hours
82. In total, how many individuals participated in group training or individual education of environmental influencers during the past year? This response should be written as a whole number (e.g., 4).E
________ individuals participated in group training
________ individuals participated in individual education of environmental influencers
Policy, regulation, or law enactment or implementation
83. During the past year, did your SPF‑Rx environmental strategy include any policy, regulation, or law enactment or implementation? This would include changing, implementing, or strengthening the implementation of new laws at the state level or working with organizations at the local level to develop or implement policies to advance the goals of SPF‑Rx (e.g., help health care provider organization institute policies to follow CDC guidelines for prescribing opioids). (Select one response.)E
Yes
No (If selected, you will skip Questions 84–89.)
84. For this particular environmental strategy, during the past year, how many different organizations did you collaborate with for the policy, regulation, or legal change, establishment, or implementation? For example, if you targeted changing policies related to opioid prescribing, count the relevant medical or governmental organizations you collaborated with for that change. Do not count individual prescribers.E
________ different organizations
85.1. During the past year, did you do any work related to changing or implementing laws, regulations, government policies, or licensing requirements as part of your SPF‑Rx efforts? For example, this could involve state laws related to the use of PDMP data or to opioid prescribing practices.E
Yes
No (If selected, you will skip Questions 85.2 and 86.)
85.2. What types of activities were you engaged in to support enactment or implementation of laws, regulations, governmental policies, or licensing requirements? (Select all that apply.)E
Met with elected officials or policymakers to educate them on the policy issues
Conducted research or analysis of policy options for officials or policymakers
Informed key stakeholders and institutions about the new policy, law, or requirement
Coordinated activities or meetings with key stakeholders and organizations
Developed informational materials (fliers, postcards, websites) related to the new policy, law, or requirement
Distributed informational materials (fliers, postcards, websites) related to the new law/policy/requirement
Other activities (Specify.)
Other activities (Specify.)
Other activities (Specify.)
86. Indicate which of the following laws, regulations, government policies, or licensing requirements you worked on during the past year as part of your SPF‑Rx effort. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities that are part of other environmental strategies that you have listed as separate interventions. Note that some items will only be applicable to the primary grantee or the subrecipient, depending on whether they are state or local types of activities. For example, state-level grantees may be more involved in state-level legislative issues (e.g., PDMP laws) than subrecipient communities are.
Please check the boxes below for any changes to specific laws, regulations, government policies, or licensing requirements that you worked on during the past year. Then indicate whether your activities related to change (enactment) or implementation of the new law, regulation, governmental policy, or licensing requirement. (Select all that apply.)E
Possible changes to PDMP-related policies, regulations, or laws at the state level:
Require universal prescriber registration with the PDMP
Involved with changing policy or law
Involved with implementation
Allow doctors to assign authorized delegates to access PDMP data
Involved with changing policy or law
Involved with implementation
Have state rules that delineate circumstances when prescribers must query the PDMP for their patients’ history of opioid prescriptions
Involved with changing policy or law
Involved with implementation
Require that pharmacists upload opioid dispensing data more quickly (e.g., within 24 hours)
Involved with changing policy or law
Involved with implementation
Expand the scope of data reported to PDMP by pharmacists (e.g., source of payment)
Involved with changing policy or law
Involved with implementation
Allow expansion of PDMP data access to allow use for public health surveillance, prevention, and research
Involved with changing policy or law
Involved with implementation
Develop interstate agreements to share PDMP data (e.g., facilitate providers’ ability to query PDMPs of neighboring states)
Involved with developing policy
Involved with implementation of new policy
Create a linkage between patients’ PDMP records and their electronic health records
Involved with developing policy
Involved with implementation of new policy
Other PDMP-related policy changes:
Change the algorithm by which patients with similar names and other characteristics are aggregated
Produce regular reports from the PDMP that summarize key state or regional statistics of interest
Involved with developing policy
Involved with implementation of new policy
Produce unsolicited reports from the PDMP
Involved with developing policy
Involved with implementation of new policy
For which group are the new unsolicited reports? (check all that apply):
Prescribers (Describe purpose.) ________________________________________
Dispensers (Describe purpose.) _________________________________________
Licensing boards (Describe purpose.) ____________________________________
Law enforcement agencies (Describe purpose.) ____________________________
Other group (Specify and describe purpose.) ______________________________
Other PDMP-related policy change (Specify). __________________________________
Other PDMP-related policy change (Specify). __________________________________
Possible changes to prescription related policies, regulations, or laws:
Mandate prescriber training on safe opioid prescribing
Involved with changing policy, regulation, or medical licensing board requirement
Involved with implementation of new requirement
Limit dose of opioid prescription (e.g., 90 MME/day) without special approval
Involved with changing state guidelines or state insurance/Medicaid pharmacy policy
Involved with implementation of new guidelines/policies
Limit duration of opioid prescription for chronic noncancer pain patients without special approval
Involved with changing state guidelines or state insurance pharmacy policies
Involved with implementation of new guidelines/policies
Require pain clinics to be regularly certified by state medical board
Involved with changing law/regulations, policy, or medical board requirement
Involved with implementation of new requirement
Require pain clinics to be owned and operated by licensed physicians
Involved with changing law/regulations, policy, or medical board requirement
Involved with implementation of new requirement
Other changes to laws or policies
Describe any other regulations or laws related to SPF‑Rx that you worked on in the past year. (3,000-character limit)
Involved with changing law/policy
Involved with implementation
87.1. Did you work with individual organizations (e.g., local hospitals, local primary care organizations, pharmacies, insurers) to help them to develop or implement organizational policies related to SPF‑Rx goals? E
Yes
No (If selected, you will skip Questions 87.2 and 88.)
87.2. Please check the boxes below to indicate any SPF‑Rx program activities in this reporting period related to helping institutions develop or implement organizational policies. (Select all that apply.)E
PDMP data organizational policy
Worked with medical organizations to incorporate or implement policies to register health care providers/prescribers with the PDMP
Worked with medical organizations to incorporate or implement policies requiring their medical providers to query their patients’ PDMP records before prescribing opioids
Worked with pharmacy organizations to incorporate or implement policies to improve timeliness of PDMP upload
Worked with organizations to incorporate or implement policies to improve scope or quality of PDMP data
Worked with organizations to establish policies or agreements related to linkage of patient PDMP records with patient electronic health records (EHRs)
Worked with organizations to establish or implement policies or agreements related to linkage of PDMP data with vital records (deaths) or overdose data (e.g., emergency room visits or hospital admissions)
Worked with organizations to incorporate or implement policies to increase PDMP access or ease of use
Safe prescribing organizational policy
Helped institutions implement/incorporate national CDC (or similar state) prescribing guidelines into their rules and codes
Helped institutions incorporate alternatives to opioids for pain treatment
Helped medical or pharmacy schools to incorporate prescription drug/opioid misuse prevention-related education into their curricula
Pharmacy organizational policy
Helped organizations with pharmacy benefit strategy change (e.g., institute drug utilization reviews for high-dose opioids)
Helped pharmacies with policies related to querying PDMP for risky prescription patterns
Social access organizational policy
Helped with organizational policies related to social access, including safe storage and disposal of prescription drugs (e.g., help develop policies to facilitate broader distribution of home lock boxes to individuals filling prescriptions for opioids/controlled substances)
(Describe.)
Development of enforcement organizational policy
Collaborated with organizations (e.g., medical regulatory bodies, law enforcement) to develop enforcement policies related to pain clinics
Collaborated with medical authorities (e.g., medical board/association) to develop policies to send letters to health care providers with higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP data
Reduce consequences
Worked to enact policies to reduce the problems/consequences associated with prescription drug misuse/abuse (e.g., crime, driving under the influence of prescription drugs/opioids)
Other (Describe.)
Other (Describe.)
Other (Describe.)
Other (Describe.)
Other Organizational Policy
88. Describe any other work you did in the past year related to helping individual organizations develop or implement policies that advance SPF‑Rx goals. (3,000-character limit).E _________________________________________________________________________
89. Describe any new laws, regulations, policies, or licensing requirements that were enacted, established, or implemented during the past year related to this particular environmental strategy.E
(3,000-character limit.)
Enforcement implementation
This section relates to the implementation of enforcement activities. (Development of new enforcement-related policies should be reported in the policy section.) Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate environmental strategies.
90.1. Did your environmental strategy include enforcement implementation efforts (e.g., collaboration with law enforcement or medical/pharmaceutical authorities to respond to possible prescription drug diversion)? (Select one response.)E
Yes
No (If selected, you will skip Questions 90.2–91.2.)
90.2. Indicate which of the following activities you worked to implement during the past year related to enforcement.E
Collaborated with organizations (e.g., pharmacies, law enforcement) to prevent or respond to suspected diversion
Collaborated with organizations to enforce policies, laws, or regulations related to pain clinics
Collaborated with organizations to enforce policies or guidelines related to opioid prescribing
Collaborated with organizations to send letters or reports to health care providers with higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP data
Other major enforcement-related practices or activities in the past year (Describe; 3,000‑character limit.)
91.1. For this environmental strategy of enforcement, did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community) during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 91.2.)
91.2. How many different law enforcement agencies were engaged in collaboration during the past year for enforcement? This response should be written as a whole number (e.g., 4).E
________ law enforcement agencies engaged
Other environmental interventions
92.1. During the past year, did you work on any environmental strategies related to safe disposal of prescription drugs, specifically, installing prescription drug drop boxes in pharmacies or law enforcement agencies or supporting take-back events? E
Yes
No (If selected, you will skip Questions 92.2–92.4.)
92.2. How many prescription drop boxes were already in your target geographic area before you began implementing SPF‑Rx)? B __________
92.3. During the past year, how many prescription drug boxes did you install? Enter total for each type of location.E
_________ installed in law enforcement agencies
_________ installed in pharmacies
_________ installed other locations
92.4. How many prescription drug take-back events did you organize, support, or participate in?E _________
93. During the past year, did you engage in any activities to increase the distribution or access to home lock boxes or Deterra bags for prescription drugs? E
Yes (Describe; 3,000-character limit.) ____________________________________
No
94. During the past year, did you engage in any other environmental strategies that did not fall into the categories of policy, enforcement, or training of environmental influencers? Describe any other environmental strategy you worked to or did implement during the past year.E
Yes (Describe; 3,000-character limit.)
No
95.1. For your “other environmental interventions,” (Question 92 or Question 94) did you collaborate with law enforcement? (Select one response.)E
Yes
No (If selected, you will skip Question 95.2.)
95.2. How many different law enforcement agencies were engaged in collaboration during the past year? This response should be written as a whole number (e.g., 4).E
________ law enforcement agencies engaged
96. As part of your environmental strategy, did you work to implement any other enforcement practices or conduct other activities to affect the implementation of enforcement activities during the past year? (Select one response.)E
Yes (Describe; 3,000-character limit.)
No
Overall Population of Focus reach by this intervention-service type
The questions in this section collect information on the individuals ultimately reached or affected through your training of environmental influencers, enforcement efforts, policy-related activities, or other environmental strategies. This goes beyond the number of individuals directly involved in the training, policy change, or enforcement to estimate the numbers affected in the targeted population in your entire community. This set of questions specifically refers to [NAME OF INTERVENTION-SERVICE TYPE ACTIVITY].
97. Estimate the total number of individuals who were reached or affected by your environmental strategy during the past year. If you are unsure of the exact number of individuals affected respond with your best estimate.E
_________ total individuals (If none, enter “0”.)
Information Dissemination Sub-Form
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
Service Type: ___________________________________________ E (autofill from Question 26)
This sub-form focuses on information dissemination activities to change community attitudes, building awareness of substance use issues to reduce their incidence and prevalence, and changing behavior. The strategy is characterized by one-way communication from source to audience. Report all media and communication campaigns (e.g., social marketing campaigns) in this section.
Please report on information dissemination activities that directly relate to educating policymakers about policies, laws, or regulations in the environmental strategies section. Note that publicity for a specific environmental strategies event (e.g., fliers to promote a drug take-back day or the installation of a new prescription drug box) should not be reported as a separate information dissemination activity. However, if you conduct an information dissemination campaign to promote use of existing prescription drug drop boxes, you would report that in this Information Dissemination sub-form.
102. What was/were the intended purpose(s) of the communication or information that you disseminated for this service type? (Select all that apply.) E
To raise awareness of prescription drug misuse prevention problems in the community
To gain support from the community for prescription drug misuse prevention efforts
To provide information on community norms related to prescription drug misuse
To provide information on the dangers of sharing medications and misusing prescription drugs
To provide prescription drug misuse prevention information (e.g., information on securing prescription drugs in the household, information on resisting offers for sharing prescription/pharmaceutical drugs)
To change individual behaviors with regard to prescription drug misuse
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 suspect prescription drug diversion)
To provide a directory of community resources for prevention of prescription drug misuse and abuse
Other (Describe.)
103. For this intervention-service type activity, indicate the community members and groups (i.e., target audience) to whom you are disseminating the information. (Select all that apply.)E
Health care providers/medical community
Pharmacists/pharmacy community
The general public
Youth groups or representatives
Schools or school districts
Youth-serving organizations other than schools (e.g., Big Brothers/Big Sisters, Boy Scouts/Girl Scouts)
Parents, family, or caregiver groups
Organizations serving seniors/older population
Advocacy volunteers
Business community
Media (e.g., radio and television stations, newspapers and magazines)
Faith-based organizations (e.g., churches, charitable organizations with religious affiliations such as Catholic Charities)
Civic or volunteer organizations (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)
LGBTQ-supportive organization
Military or veteran organization
Law enforcement agencies (e.g., local, tribal, state, and Federal law enforcement agencies, including the police, the Federal Bureau of Investigation [FBI], and the Drug Enforcement Administration [DEA],
Local or state, tribal, or jurisdiction courts
State departments of justice (e.g., judicial department, department of juvenile justice, department of criminal justice, attorney general’s office)
State, tribal, or local jails and prisons
State, tribal, jurisdiction, or local public health departments
Mental health professionals or agencies
Other state, tribal, or jurisdiction government agencies (e.g., public health, public safety, social services, American Indian tribal government)
Local, village, or tribal agencies (mayor’s office, city council, tribal council, Alaska Native Corporation agencies)
Other (Describe.)
104. For this intervention-service type activity, indicate the total number of different community groups or organizations to whom you disseminated information during the past year, if any. This response should be written as a whole number (e.g., 4).E
________ community groups or organizations (If none, enter “0.”)
106. Indicate the type(s) of individuals targeted by this information dissemination service type activity during the past Federal fiscal year.E (autofill after first completed)
106.1. Age group(s) targeted by information dissemination service type activity during the past Federal fiscal year: (Select all that apply.) E
Children age 0 to 11
Youth age 12 to 17
Young adults age 18 to 25
Adults age 26 or older
Other (Describe.)
106.2. Population type(s) targeted by this information dissemination service type activity during the past Federal fiscal year: (Select all that apply.) E
Middle school students
High school students
College students
Parents
Health care providers
Employees
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
107.1. For this particular information dissemination service type activity, did you create or air television ads during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 107.2–107.5.)
107.2. How many individual times did the television ads air during the past year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ times
107.3. How many weeks did the television ads air during the past year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ weeks
107.4. How many different televisions stations aired the ads air during the past year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ stations
107.5. Provide any information you have on the reach of the television ads aired during the past year. This could include information provided by the television stations or advertising agency on ratings points; the average number of viewers at the time the ads aired; the geographic area where the ads aired; and the target audience of the related television programs.E
(Describe; 3,000-character
limit.)
108.1. For this particular information dissemination service type activity, did you create or air radio ads during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 108.2–108.5.)
108.2. How many individual times did the radio ads air during the past year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ times
108.3. How many weeks did the radio ads air during the past year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ weeks
108.4. How many different radio stations aired the ads air during the past year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ stations
108.5. Provide any information you have on the reach of the radio ads aired during the past year. This could include information provided by the radio stations or advertising agency on ratings points; the average number of listeners at the time the ads aired; the geographic area where the ads aired; and the target audience of the related radio broadcast.E
(Describe; 3,000-character limit.)
109.1. For this particular information dissemination service type activity, did you create or publish print ads during the past year? (Select one response.)E
Yes
No (If selected, you will skip Questions 109.2–109.4.)
109.2. How many individual times did the print ads run during the past year? (Select one response.)E
________ times
109.3. How many different newspapers or magazines displayed the ads during the past year? Insert “0” if ads were created but not distributed during the period. This response should be written as a whole number (e.g., 4).E
________ newspapers or magazines
109.4. Provide any information you have on the reach of the print ads run during the past year. This could include information provided by the newspaper or magazine on its average readership; the geographic area in which the publication was distributed; and the target audience of the publication.E
(Describe; 3,000-character limit.)
110. For this particular information dissemination service type activity, how many special events (e.g., invited speakers) were hosted during the past year? This response should be written as a whole number (e.g., 4).E
________ special events
111. For this particular information dissemination service type activity, how many other promotional activities (e.g., distributing prescription drug take-back information at a health fair) were implemented during the past year? This response should be written as a whole number (e.g., 4).E
________ promotional activities
112.1. For this particular information dissemination service type activity, did you present at community meetings (e.g., parent-teacher association [PTA] meetings, town hall meetings, school assemblies) during the past year? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select one response.)E
Yes
No (If selected, you will skip Questions 112.2 and 112.3.)
112.2. How many community meetings did you present at during the past year? This response should be written as a whole number (e.g., 4).E
________ meetings
112.3. What was the total number of participants at all community meetings where you presented during the past year? This response should be written as a whole number (e.g., 4).E
________ participants
113.1. For this particular information dissemination service type activity, did you send any letters to the editor of the local newspaper or community newsletters during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 113.2.)
113.2. How many letters were published during the past year? This response should be written as a whole number (e.g., 4).E
________ letters
114.1. For this particular information dissemination service type activity, did you produce or distribute prescription drug misuse prevention posters during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 114.2.)
114.2. How many posters were distributed during the past year? This response should be written as a whole number (e.g., 4).E
________ posters
115.1. For this particular information dissemination service type activity, did you produce or distribute prescription drug misuse prevention brochures during the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 115.2.)
115.2. How many brochures were distributed during the past year? This response should be written as a whole number (e.g., 50).E
________ brochures
116.1. For this particular information dissemination service type activity, did you provide a related information line or hotline in the past year? (Select one response.)E
Yes
No (If selected, you will skip Question 116.2.)
116.2. How many individuals called into the information line or hotline in the past year? This response should be written as a whole number (e.g., 50).E
________ individuals
117. For this particular information dissemination service type activity, did you develop or run a prescription drug misuse prevention-focused clearinghouse or information resource center in the past year? (Select one response.) E
Yes
No
118.1. For this particular information dissemination service type activity, during the past year, did you launch or maintain any web sites or social media platforms focused on prescription drug misuse prevention? (Select all that apply.)E
Web site(s) (If selected, answer Questions 118.2 and 118.3.)
Facebook (If selected, answer Questions 118.2 and 118.3.)
Twitter
Instagram
Tumblr
Snapchat
Other (Specify.) ___________
No (If selected, you will skip Questions 118.2 and 118.3.)
118.2. What is the number of visitor sessions (visits) that the web sites, including Facebook, had during the past year? This response should be written as a whole number (e.g., 4).E
Specify number of visits _____
Do not know
118.3. How many new (compared with returning) visitors did the web sites, including Facebook, have during the past year? This response should be written as a whole number (e.g., 4).E
Specify number of new visitors _____
Do not know
119. For this particular information dissemination service type activity, did you conduct other communication activities during the past year? E
Yes (Describe; 3,000-character limit.)
No
The questions in this section collect information on the individuals reached through this information dissemination service type activity.
120. Estimate the total number of individuals who were reached or affected by this information dissemination service type activities for during the past year. If you are unsure of the exact number of individuals affected, respond with your best estimate.E
________ total individuals (If none, enter “0.”)
Section 2D. Monitoring and Evaluation (Subrecipients only)
This section collects information on how you used your monitoring and evaluation findings.
125.1. Have you made changes to your prevention strategies or the implementation of your prevention interventions during the past Federal fiscal year as the result of the analysis of your monitoring and evaluation data? (Select one response.)E
Yes
No (If selected, you will skip Question 125.2.)
Data not yet collected or analyzed (If selected, you will skip Question 125.2.)
Not applicable (If selected, you will skip Question 125.2.)
125.2. How did you change your strategy, or which prevention intervention(s) did you modify during the past Federal fiscal year as the result of the analysis of your monitoring and evaluation data? E
Changed strategy (Describe.) ___________________________________________
Changed intervention (Select all that apply.):
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
[INTERVENTION NAME HERE]
126. Did you or your local evaluator work on any of the following intervention evaluation activities related to process or outcomes evaluation of your PFS interventions during the past Federal fiscal year? Process evaluation focuses on how an intervention was implemented and operates. Outcomes evaluation looks at the effect of your interventions on your targeted consumption, consequence, or intervening variables. (Select all that apply.) E
Evaluation activity |
Process evaluation |
Outcome evaluation |
126.1. Develop or substantially revise an evaluation plan |
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126.2. Collect data |
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126.3. Analyze data |
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126.4. Produce an evaluation report |
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126.5. Not applicable; no work done in past Federal fiscal year |
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Section 3: Implementation Barriers and Contextual Factors (Both grantees and subrecipients complete)
In this section, we would like to learn about possible barriers and challenges that had an impact on implementation of SPF-Rx, including all SPF steps, or outcomes related to your SPF‑Rx prevention activities in your community, state, tribal area, or jurisdiction during this reporting period. How much impact did the following factors have on the progress or results of your SPF‑Rx efforts in the past Federal fiscal year? (Select one level of impact for each factor.)
Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you can check the box “No impact.”
127. Implementation Barriers E |
No impact |
Low impact |
Moderate impact |
High impact |
127.1. Limited legal policies/laws or enforcement |
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127.2. Problems with quality of PDMP data (e.g., data cleaning, type of information available etc.) |
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127.3. Problems accessing PDMP data (or with frequency of access) |
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127.4. Problems analyzing PDMP data |
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127.5. Lack of ease of PDMP use for health care providers |
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127.6. Problems accessing hospital data to measure overdoses |
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127.7. Challenges getting buy-in and support from health care professionals |
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127.8. Challenges getting health care providers to complete PDMP training |
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127.9. Challenges getting health care providers to complete safe opioid prescribing training |
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127.10. Lack of leadership support from medical board or association |
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127.11. Lack of understanding by medical community about addiction |
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127.12. Lack of leadership support from pharmacy board or association |
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127.13. Challenges aligning priorities across public agencies |
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127.14. Lack of state leadership to prioritize prescription drug/opioid misuse prevention (e.g., governor’s office, legislature) |
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127.15. Challenges coordinating efforts across agencies |
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127.16. Challenges collaborating between public health and substance abuse agencies |
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127.17. Challenges for substance abuse/mental health agencies to focus on prevention, given demands for treatment |
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127.18. Challenges trying to cover geographic areas that are too broad |
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127.19. Lack of relevant prevention interventions for specific populations at risk |
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127.20. Not enough funds for prevention efforts for prescription drug/opioid misuse and abuse |
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127.21. Cost of prescription drug home lock boxes |
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127.22. Lack of resources to pay for prescription drug drop boxes in enough pharmacies or police stations |
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127.23. Problems with disposal of returned prescription drugs |
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127.24. Lack of transportation of community members to attend interventions (e.g., parents and youth) |
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127.25. Cultural barriers |
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127.26. Language barriers |
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127.27. Other (Describe.) ___________________ |
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127.28. Other (Describe.) ___________________ |
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127.29. Other (Describe.) ___________________ |
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127.30. Other (Describe.) ___________________ |
|
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128. To what extent do you think the following contextual factors affected SPF‑Rx-related implementation or outcomes in your community, state, tribal area, or jurisdiction during the past Federal fiscal year? (Select one level of impact for each factor.) B, F
128. Broader Contextual Factors B,F |
No impact |
Low impact |
Moderate impact |
High impact |
128.1. Lack of available mental health treatment (i.e., leading to self-medicating) |
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128.2. Lack of available substance abuse treatment |
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128.3. Lack of access to medical care and better treatment options for chronic medical conditions, including pain |
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128.4. Lack of community awareness of the risk factors, extent, or consequences of prescription drug/opioid misuse |
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128.5. Easy access to prescription drugs for misuse |
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128.6. Lack of trust in government agencies (i.e., public health authorities, social services, or law enforcement) |
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128.7. High poverty rates/low socioeconomic status |
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128.8. High unemployment, underemployment, or economic dislocation |
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128.9. Low literacy or low education levels |
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128.10. Community social disorganization |
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128.11. Social isolation |
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128.12. Lack of opportunities for area youth |
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128.13. Cultural norms, attitudes, or practices favoring substance use |
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128.14. Cultural norms, attitudes, or practices that are resistant to identifying and serving drug-dependent individuals |
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128.15. Stigmatization of drug-dependent individuals in the community |
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128.16. Stressful events affecting large portions of the population of focus (e.g., natural disasters or other unexpected traumatic community events) (Describe.) _________________ |
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128.17. Historical trauma experienced by racial/ethnic groups |
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128.18. Other
(Describe.)
__________________ |
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128.19. Other
(Describe.)
__________________ |
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128.20. Other
(Describe.)
__________________ |
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Section 4: Closing Questions (Both grantees and subrecipients complete)
129. Provide any additional comments about your SPF‑Rx-related prevention intervention activities here. (Describe; 3,000-character limit.) E
130. Do you have any additional comments about any aspects of the SPF‑Rx Initiative? (Describe; 3,000-character limit.) E
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CLI Part 1 Revision |
| Author | DACCC |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |
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