OMB Control Number: 0970-0401
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Q1 Indicate your Grant Number:
Q2 Indicate your Grant Name:
Q3 Does your agency have any strategies related to opioid misuse?
Yes [ ] – If yes, go to Q3b
No [ ] – If no, go to Q4
Q3b Are these strategies targeting any of the following? (please respond to each category)
Staff - Yes/No
Parents/caregivers - Yes/No Yes to any Q3b1
Children - Yes/No
Q3b1 - Do these strategies _______ (survey monkey fills in what the grantee responded to as yes in Q3b) include collaboration with community partners? Yes/No to each Yes from Q3b
Q3b2 How long have you been engaged in these strategies? (if yes to Q3b then the target is included here (staff, parents/caregivers, children))
Within last year
Within last 2 years
More than that 2 years ago
If yes (to Q3b), please fully describe your efforts including what this strategy looks like on the ground in your program.
Q4 Thank you for responding to this questionnaire, feel free to provide any comments you may have regarding the opioid epidemic and how it has impacted your agency.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jesse Escobar |
| File Modified | 0000-00-00 |
| File Created | 2021-05-04 |