FY 2020-2021SABG Report 8-2021 _

Tables 21 – 30 Prevention Performance Measures

Tables 21 through 30 Information

D. Instructions for Completing Forms

Column B: Question/Response

The following chart is for collecting information on the reporting periods for the data entered in Tables 31-35. Please note that the correct reporting period for Tables 31-34 is the Calendar Year (CY) which coincides with the reporting period for the pre-populated prevention NOMs in Tables 21-30. We understand that some states have reported on the state fiscal year (SFY) or federal fiscal year (FFY) for these tables in past SABG Reports. If your state is unable to report on the calendar year, please indicate in this footnote why you are unable to report on the calendar year and the steps the state intends to take to make calendar year reporting possible in future years. Note that the correct reporting period for Table 35 is the SABG compliance period that coincides with the reporting period for Tables 4, 5a, 5b, 6 and 7.

FY 2020-2021SABG Report 8-2021 _

FY 2020-2021SABG Report 8-2021 _.docx

Community MH Services BG and SAPT BG Application Guidance and Instructions FY 2019-2021

Section A. Introduction

Treatment Performance Measures

Prevention Performance Measures

FY 2020-2021SABG Report 8-2021 _

OMB: 0930-0168

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Shape1 Block Grant Reporting Section

CFDA 93.959

Substance Abuse Prevention and Treatment Block Grant

(SABG)

U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration

Table of Contents

Introduction

Annual Update

SABG Table 1 Priority Area and Annual Performance Indicators – Progress Report

State Agency Expenditure Reports

SABG Table 2 - State Agency Expenditure Report SABG Table 3 – Syringe Services Program

SABG Table 4 - SABG State Agency Expenditure Compliance Report SABG Table 5a - SABG Primary Prevention Expenditures Checklist

SABG Table 5b - SABG Primary Prevention Expenditures by IOM Category SABG Table 5c - SABG Primary Prevention Targeted Priorities

SABG Table 6 - Systems Development/Non-Direct Service Activities Expenditure Checklist SABG Table 7 - SABG Statewide Entity Inventory

SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse Prevention and Treatment

SABG Table 8b - Base and Maintenance of Effort for Expenditures for Services to Pregnant Women and Women with Dependent Children

Population and Services Reports

SABG Table 9 - Prevention Strategy Report SABG Table 10 - Treatment Utilization Matrix

SABG Table 11 - Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use

SABG Table 12 - SABG HIV Early Intervention Services in Designated States SABG Table 13 - Charitable Choice

Performance Data and Outcomes Treatment Performance Measures

SABG Table 14 - Employment/Education Status SABG Table 15 - Stability of Housing

SABG Table 16 - Criminal Justice Involvement SABG Table 17 -Change in Abstinence–Alcohol Use

SABG Table 18 - Change in Abstinence – Other Drug Use SABG Table 19 - Change in Social Support of Recovery

SABG Table 20 - Retention Prevention Performance Measures

SABG Table 21 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: 30 Day Use

SABG Table 22 - Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure: Perception Of Risk/Harm of Use

SABG Table 23 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Age of First Use

SABG Table 24 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Perception of Disapproval/Attitudes

SABG Table 25 - Employment/Education; Measure: Perception of Workplace Policy

SABG Table 26 - Employment/Education; Measure: Average Daily School Attendance Rate SABG Table 27 - Crime and Criminal Justice; Measure: Alcohol-Related Traffic Fatalities SABG Table 28 - Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests SABG Table 29 - Social Connectedness; Measure: Family Communications around Drug and Alcohol Us

SABG Table 30 - Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or Listening to a Prevention Message

SABG Table 31 - Individual-Based Programs and Strategies; Measure: Number of Persons Served By Age, Gender, Race, and Ethnicity

SABG Table 32 - Population-Based Programs and Strategies; Measure: Number of Persons Served By Age, Gender, Race, and Ethnicity

SABG Table 33 - Number of Persons Served by Type of Intervention

SABG Table 34 - Number of Evidence-Based Programs by Types of Intervention.

SABG Table 35 - Number of Evidence-based Programs and Strategies, and Total SA Block Grant Funds Spent on Evidence-Based Programs/ Strategies.

Section 1942(a) of Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. § 300x- 52(a)) requires the Secretary of the Department of Health and Human Services, acting through the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), to determine the extent to which states¹ have implemented the State Plan for the preceding fiscal year. The purpose of the Substance Abuse Prevention and Treatment Block Grant (SABG) Annual Report is to provide information to assist the Secretary in making this determination.

States are required to prepare and submit an annual report that includes expenditure summaries for

(1) the state fiscal year (SFY) immediately preceding the federal fiscal year for which the state is applying for funds; and (2) the obligation and expenditure period of the Substance Abuse Prevention and Treatment Block Grant (SABG) Notice of Award (NoA) subject to CSAT compliance review (Compliance Award), in the format provided in this guidance. The SABG Annual Report will address the purposes for which the SABG funds were expended, the SABG sub-recipients, and the authorized activities funded and services purchased with such funds. Particular attention should be given to the progress made toward accomplishing the goals and performance indicators identified in the states’ and jurisdictions’ plans.

All States are required to prepare and submit their respective SABG Annual Reports utilizing SAMHSA’s Web Block Grant Application System (BGAS). Annual reports must be received by SAMHSA not later than December 1 in order for a state or jurisdiction to receive its fiscal year SABG NoA. If a receipt date falls on a weekend or federal holiday, the receipt date for a report will be the next business day. The following schedule provides specific due dates for the SABG Annual Reports, MHBG Implementation Reports and the Annual Synar Reports:

Due Dates for SA Only and MHBG/SABG Applications
FY for which the state is applying for funds	Application Due	Plan Due	Planning Period	SABG Report Due	Synar Report Due
2020	9/3/2019	Yes	7/1/19 – 6/30/21	12/1/2019 Compliance Year is 2017	12/31/2019
2021	9/1/2020	No*	NA	12/1/2020 Compliance Year is 2018	12/31/2020

Receipt Dates for Reports
Applicable FY	SABG Annual Report	MHBG Implementation Report	Annual Synar Report
2020	12/01/2019	12/01/2019	12/31/2019
2021	12/01/2020	12/01/2020	12/31/2020

¹ The term ”state” means each of the several states, the District of Columbia and each of the territories of the United States. The term “territories of the United States” means each of the Commonwealth of Puerto Rico, Virgin Islands, American Samoa, Commonwealth of the Northern Marianas Islands, Federated States of Micronesia, Guam, Republic of the Marshall Islands and the Republic of Palau

² The term “substance use disorder “ means substance-related and addictive disorders as described in the Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.

States are required to prepare and submit an annual report comprised of the following sections:

Section B: Annual Update - In this section, states are required to provide a brief review of the extent to which their respective plans were implemented, and the progress toward the priorities and goals identified in the SABG plan covering SFY 2019 and 2020. The report should also include a brief review of areas that the state identified in that SABG plan as needing improvement and changes that the state or jurisdiction proposed to achieve the goals established for the priorities.

Section C: State Agency Expenditure Reports - In this section, states must provide information regarding expenditures for authorized activities and services for substance misuse prevention, substance use disorder² (SUD) treatment and recovery. The state must provide a description of SABG expenditures for authorized activities to prevent substance misuse and treat SUDs and related services for tuberculosis, and, if it is a “designated State,” a description of SABG expenditures for early intervention services for regarding the human immunodeficiency virus (EIS/HIV). In addition, the state must identify the SABG expenditures made available to intermediaries, administrative service organizations, and community- and faith-based organizations that received amounts from the SABG to provide authorized activities to prevent and treat SUDs.

Section D: Populations and Services Reports - In this section, states must provide specific information regarding the number of individuals that were served with SABG funds. In addition, states should provide specific information regarding the services these individuals received.

Section E: Performance Indicators and Accomplishments - In this section of the report, states are required to complete the Performance Indicator tables. Performance indicators should be reported using the table format provided in this document. The purpose of the performance indicator tables is to show progress made over time as measured by SAMHSA’s National Outcome Measures (NOMS) for substance misuse prevention, SUD treatment and recovery.

Annual Update

The information states entered into SABG Table 1 in the planning section of the 2020/2021 Behavioral Health Assessment and Plan will automatically populate cells 1 - 6 in the progress report table below. States are required to indicate whether each first-year performance target/outcome measurement identified in 6.b below (from the 202/2021 Plan) was “Achieved” or “Not Achieved” in Cell 7, Report of Progress toward Goal Attainment. If a target was not achieved, a detailed explanation must be provided, as well as the remedial steps proposed to meet the target.

SABG Table 1 - Priority Areas and Annual Performance Indicators – Progress Report

Priority Areas and Annual Performance Indicators
1. Priority Area:	2. Priority Type (SAP, SAT, MHS):
3. Population(s) (SMI, SED, FEP, PWWDC, PP, PWID (formerly IVDUs), EIS/HIV, TB, OTHER):
4. Goal of the Priority Area:
5. Strategies to Attain the Goal:
6. Annual Performance Indicators to Measure Goal Success:
Indicator #1:
a) Baseline measurement (Initial data collected prior to the first-year target/outcome):
b) First-year target/outcome measurement (Progress – end of SFY 2020):
c) Second-year target/outcome measurement (Final – end of SFY 2021):
d) Data source:
e) Description of data:
f) Data issues/caveats that affect outcome measures:
7. Report of Progress toward Goal Attainment: First-year target: Achieved Not Achieved (If not achieved, explain why.)
Reason why target was not achieved, and changes proposed to meet target:

State Agency Expenditure Reports

States are required to provide information regarding SABG and state funds expended for authorized activities to prevent and treat SUDs and for related public health services, e.g., tuberculosis services (TB) and, if applicable, early intervention services regarding the human immunodeficiency virus (EIS/HIV). Please complete the tables described below:

SABG Table 2A - State Agency Expenditure Report This table provides a report of SABG, COVID-19, and state expenditures by the principal agency of a state, i.e., single state agency (SSA), during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. Expenditures to be reported are for authorized activities to prevent and treat SUDs pursuant to section 1921 of Title XIX, Part B, Subpart II of the Public Health Service (PHS) Act (42 U.S.C. § 300x-21); tuberculosis services; early intervention services regarding the human immunodeficiency virus (EIS/HIV), if applicable; pursuant to section 1924(b) of Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. § 300x-24(b)); and administration pursuant to section 1931(a)(2) of Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. § 300x-31(a)(2)). In column A, the applicable federal fiscal years’ SABG funds expended during the state fiscal year should be included.

SABG Table 2B – COVID-19 Relief Supplement Funds Expenditure by Service. This table provides a report of COVID-19 Relief Supplement expenditures for services to assist states in responding to the COVID-19 pandemic.

SABG Table 3 – Syringe Services Program This table provides a report of SABG and COVID expenditures for elements of syringe services programs carried out by SABG sub-recipients as described in the guidance disseminated by the Office of HIV/AIDS and Infectious Disease Policy, the Centers for Disease Control and Prevention, National Center on HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of HIV Prevention and SAMHSA. The authorization to expend federal funds for elements of a syringe services program is subject to an authorization in the annual appropriations’ bill(s).

SABG Table 4 - SABG State Agency Expenditure Compliance Report This table provides a report of expenditures for authorized activities to prevent and treat SUDs associated with a SABG Notice of Award (NoA) for the applicable fiscal year. It covers the two-year obligation and expenditure period.

SABG Table 5a- SABG Primary Prevention Expenditures Checklist This table provides a report of primary prevention expenditures associated with a SABG NoA for the applicable fiscal year. It covers the two-year obligation and expenditure period. Table 5a excludes Expenditures for Systems Development/Non-Direct Service Activities (formerly known as Resource Development expenditures).

SABG Table 5b- SABG Primary Prevention Expenditures by IOM Category This table provides a report of primary prevention expenditures by Institute of Medicine (IOM) categories associated with a SABG NoA for the applicable fiscal year. It covers the two-year obligation and expenditure period. Table 5b excludes Expenditures for Systems Development/Non-Direct Service Activities (formerly known as Resource Development expenditures).

SABG Table 5c - SABG Primary Prevention Targeted Priorities This requested table provides a report of actual state primary prevention priorities and special population categories on which the state expended primary prevention funds from the SABG NoA for the applicable fiscal year.

SABG Table 6 – Expenditures for System Development/Non-Direct Service Activities This table provides a report of expenditures from the SABG and COVID-19 NoAs for system development and non-direct service activities that were supported by the SABG and COVID-19 awards. NoA for the applicable fiscal year.

SABG Table 7 – SABG Statewide Entity Inventory This table provides a report of the SABG sub- recipients including community- and faith-based organizations which provided SUD prevention activities and treatment services, as well as intermediaries/administrative service organizations. Table 7 excludes Expenditures for Systems Development/Non-Direct Service Activities (formerly known as Resource Development expenditures).

SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse Prevention and Treatment This table provides a report of aggregate state expenditures by the SSA for authorized activities to prevent and treat SUDs during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds.

SABG Table 8b - Base and Maintenance of Effort for Expenditures for Services to Pregnant Women and Women with Dependent Children This table provides a report of SABG and/or state funds pursuant to 42 U.S.C. § 300x-22(b) and 45 CFR § 96.124(c)(3) expended to establish new programs or expand the capacity of existing programs designed to serve pregnant women and women with dependent children and the services required pursuant to 45 CFR § 96.124(e) to address the treatment and recovery needs of such women during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds.

SABG Table 2 - State Agency Expenditure Report

This table provides a report of SABG and state expenditures by the SSA during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds for authorized activities to prevent and treat SUDs. For detailed instructions, refer to those in the Block Grant Application System (BGAS).

State Agency Expenditure Report
SABG Table 2A
State Identifier:
Report Period- From: To:
(Include ONLY funds expended by the executive branch agency administering the Substance Abuse Block Grant)
Source of Funds
ACTIVITY (See instructions for using Row 1.)	A. SABG	B. MHBG	C. Medicaid (Federal, State, and local)	D. Other Federal Funds (e.g., ACF (TANF), CDC, CMS (Medicare) SAMHSA, etc.)	E. State funds	F. Local funds (excluding local Medicaid)	G. Other	H. COVID-19⁰
Substance Abuse Prevention⁰ and Treatment
Pregnant Women and Women with Dependent Children²
All Other
Primary Prevention
Tuberculosis Services
Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV)⁰
Administration (excluding program / provider level administration)
8. Total

Table 2b - COVID-19 Relief Supplemental Funds Expenditure by Service

Expenditure Period Start Date: 3/15/2021 Expenditure Period End Date: 9/30/2021

Shape2

8. TotalService	Expenditures
Healthcare Home/Physical Health	$
Specialized Outpatient Medical Services
Acute Primary Care
COVID-19 Screening (e.g., temperature checks, symptom questionnaires)
COVID-19 Testing
COVID-19 Vaccination
Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community Services Dissemination
Prevention (Including Promotion)
Screening with Evidence-based Tools
Risk Messaging
Access Line/Crisis Phone Line/Warm Line
Purchase of Technical Assistance
COVID-19 Awareness and Education for Person with SUD
Media Campaigns (Information Dissemination)
Employee Assistance Programs (Problem Identification and Referral)
Intervention Services
Fentanyl Strips
Syringe Services Program
Naloxone
Overdose Kits/Dissemination of Overdose Kits
Engagement Services
Assessment
Specialized Evaluations (Psychological and Neurological)
Services Planning (including crisis planning)
Consumer/Family Education
Outreach (including hiring of outreach workers)
Outpatient Services
Evidence-based Therapies
Group Therapy
Family Therapy
Multi-family Therapy
Consultation to Caregivers
Medication Services
Medication Management
Pharmacotherapy (including MAT)
Laboratory Services
Community Support (Rehabilitative)
Parent/Caregiver Support
Case Management
Behavior Management
Supported Employment
Permanent Supported Housing
Recovery Housing
Recovery Supports
Peer Support
Recovery Support Coaching
Recovery Support Center Services
Supports for Self-Directed Care
Supports (Habilitative)
Personal Care
Respite
Supported Education
Acute Intensive Services
Mobile Crisis
Peer-based Crisis Services
Urgent Care
23-hour Observation Bed
Medically Monitored Intensive Inpatient for SUD
24/7 Crisis Hotline
Other
Smartphone Apps
Personal Protective Equipment
Virtual/Telehealth/Telemedicine Services
Purchase of increased connectivity (e.g., Wi-Fi)
Cost-sharing Assistance (e.g., copayments, coinsurance and deductibles)
Provider Stabilization Payments
Transportation to COVID-19 Services (e.g., testing, vaccination)
Other (Please List)

*Only designated states as defined in 42 U.S.C. § 300x-24(b)(2) and 45 CFR § 96.128(b) for the applicable federal fiscal year should enter information in this row. This may include a state or states that were previously considered “designated states” during any of the thre prior federal fiscal years for which a state was applying for a grant. See EIs/HIV policy change in SABG Annual Report instructions.

Table 2B

Service	Expenditures
Healthcare Home/Physical Health	$
Specialized Outpatient Medical Services
Acute Primary Care
COVID-19 Screening (e.g., temperature checks, symptom questionnaires)
COVID-19 Testing
COVID-19 Vaccination
Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community Services Dissemination
Prevention (Including Promotion)
Screening with Evidence-based Tools
Risk Messaging
Access Line/Crisis Phone Line/Warm Line
Purchase of Technical Assistance
COVID-19 Awareness and Education for Person with SUD
Media Campaigns (Information Dissemination)
Primary Substance Use Disorder Prevention (Education)
Primary Substance Use Disorder Prevention (Alternatives)
Employee Assistance Programs (Problem Identification and Referral)
Primary Substance Use Disorder Prevention (Community-Based Processes)
Primary Substance Use Disorder Prevention (Environmental)
Intervention Services
Fentanyl Strips
Syringe Services Program
Naloxone
Overdose Kits/Dissemination of Overdose Kits
Engagement Services
Assessment
Specialized Evaluations (Psychological and Neurological)
Services Planning (including crisis planning)
Consumer/Family Education
Outreach (including hiring of outreach workers)
Outpatient Services
Evidence-based Therapies
Group Therapy
Family Therapy
Multi-family Therapy
Consultation to Caregivers
Medication Services
Medication Management
Pharmacotherapy (including MAT)
Laboratory Services
Community Support (Rehabilitative)
Parent/Caregiver Support
Case Management
Behavior Management
Supported Employment
Permanent Supported Housing
Recovery Housing
Recovery Supports
Peer Support
Recovery Support Coaching
Recovery Support Center Services
Supports for Self-Directed Care
Supports (Habilitative)
Personal Care
Respite
Supported Education
Acute Intensive Services
Mobile Crisis
Peer-based Crisis Services
Urgent Care
23-hour Observation Bed
Medically Monitored Intensive Inpatient for SUD
24/7 Crisis Hotline
Other
Smartphone Apps
Personal Protective Equipment
Virtual/Telehealth/Telemedicine Services
Purchase of increased connectivity (e.g., Wi-Fi)
Cost-sharing Assistance (e.g., copayments, coinsurance and deductibles)
Provider Stabilization Payments
Transportation to COVID-19 Services (e.g., testing, vaccination)
Other (Please List)

SABG Table 3 – Syringe Services Program

Table 3 provides a report of SABG, COVID-19, and state expenditures by the SSA during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds for authorized activities to prevent and treat SUDs. For detailed instructions, refer to those in the Block Grant Application System (BGAS).

Shape3

Table 3A Syringe Services Program
Report period From: To:
State Identifier:
Syringe Services Program (SSP) Agency Name	Main Address of SSP	Dollar amount of SABG funds used for SSP	Dollar amount of COVID-19 Relief Supplemental Funds Expended for SSP⁰	SUD Treatment Provider (Yes or No)		# of locations (include any mobile locations)	Narcan® Provider (Yes or No)		Fentanyl Strips (Yes or No)
				Yes	No		Yes	No	Yes	No

Table 3B SABG - Syringe Services Program

This table is intended to capture the unduplicated count of persons that received onsite services from an SSP or were referred to services by an SSP including HIV, Hepatitis C, and sexually transmitted disease testing, treatment for substance use conditions, and treatment for physical health.

SABG

Syringe Services Program Name

# of Unique Individuals Served

HIV

Testing (Please enter total number of individuals served)

Treatment for Substance Use Conditions (Please enter total number of individuals served)

Treatment for Physical Health (Please enter total number of individuals served)

STD

Testing (Please enter total number of individuals served)

Hep C

(Please enter total number of individuals served)

ONSITE

testing

REFERRAL to

testing

ONSITE

treatment

REFERRAL to

treatment

ONSITE

treatment

REFERRAL to

treatment

ONSITE

testing

REFERRAL to

testing

ONSITE

testing

REFERRAL to

testing

COVID-19⁰

Syringe Services Program Name

# of Unique Individuals Served

HIV

Testing (Please enter total number of individuals served)

Treatment for Substance Use Conditions (Please enter total number of individuals served)

Treatment for Physical Health (Please enter total number of individuals served)

STD

Testing (Please enter total number of individuals served)

Hep C

(Please enter total number of individuals served)

ONSITE

testing

REFERRAL to

testing

ONSITE

treatment

REFERRAL to

treatment

ONSITE

treatment

REFERRAL to

treatment

ONSITE

testing

REFERRAL to

testing

ONSITE

testing

REFERRAL to

testing

SABG Table 4 - State Agency SABG Expenditure Compliance Report

This table provides a description of SABG expenditures for authorized activities to prevent and treat SUDs. For detailed instructions, refer to those in BGAS. Only one column is to be filled in each year.

State Agency SABG Expenditure Compliance Report
SABG Table 4	FY 2016 SA Block Grant Award	FY 2017 SA Block Grant Award
State Identifier:
Expenditure Category

1. Substance Abuse Prevention* and Treatment
2. Primary Prevention
3. Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV)**
4. Tuberculosis Services
5. Administration (excluding program / provider level)
6. Total

* Prevention other than Primary Prevention

** Only designated states as defined in 42 U.S.C. § 300x-24(b)(2) and 45 CFR § 96.128(b) for the applicable federal fiscal year should enter information in this row. This may include a state or states that were previously considered “designated states” during any of the thre prior federal fiscal years for which a state was applying for a grant. See EIs/HIV policy change in SABG Annual Report instructions

SABG Table 5a - Primary Prevention Expenditures Checklist

The State or jurisdiction must complete either SABG Table 5a and/or 5b. There are six primary prevention strategies typically funded by principal agencies administering the SABG. Expenditures within each of the six strategies or Institute of Medicine Model (IOM) should be directly associated with the cost of completing the activity or task. For example, information dissemination may include the cost of developing pamphlets, the time of participating staff and/or the cost of public service announcements, etc. If a state or jurisdiction employs strategies not covered by these six categories, please report them under “Other,” each in a separate row.

Section 1926 – Tobacco: Costs associated with the Synar Program Pursuant to the January 19, 1996 federal regulation “Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants, Final Rule” (45 CFR § 96.130), a state may not use the SABG to fund the enforcement of its statute, except that it may expend funds from its primary prevention set aside of its Block Grant allotment under 45 CFR § 96.124(b)(1) for carrying out the administrative aspects of the requirements, such as the development of the sample design and the conducting of the inspections.

States should include any non-SABG funds* that were allotted for Synar activities in the appropriate columns under 7 below.

Plan Table 5a: SABG Primary Prevention Planned Expenditures
Planning Period Start Date: 10/1/2019 Planning Period Start Date: 9/30/2021
	A	B	C	D	E
Strategy	IOM Target	FFY 2020 SA Block Grant Award	FFY 2021 SA Block Grant Award	COVID-19¹	ARP²
1. Information Dissemination	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total
2. Education	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total
3. Alternatives	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
4. Problem Identification and Referral to Education	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total
5. Community-Based Processes	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total
6. Environmental	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total
7. Section 1926-Tobacco	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total
8. Other	Universal	$	$	$	$
	Selected	$	$	$	$
	Indicated	$	$	$	$
	Unspecified	$	$	$	$
	Total	$	$	$	$
Total Prevention Expenditures
Total SABG Award*		$	$	$	$
Planned Primary Prevention Percentage		%	%	%	%

*Total SABG Award is populated from Table 4 - SABG Planned Expenditures

¹The 24-month expenditure period for the COVID-19 Relief Supplemental funding is March 15, 2021 – March 14, 2023. Per the instructions, the planning period for the standard SABG expenditures for the FFY 2021 SABG Award is October 1, 2020 – September 30, 2021. For purposes of this table, all COVID-19 Relief Supplemental expenditures between March 15, 2021 and September 30, 2021 should be entered in this column.

²The expenditure period for The American Rescue Plan Act of 2021 (ARP) supplemental funding is September 1, 2021 - September 30, 2025, which is different from the expenditure period for the FY 2021 "standard" SABG, which is October 1, 2020 - September 30, 2021. The planned expenditures for the period of September 1, 2021 - September 30, 2021 should be entered here.

SABG Table 5b - SABG Primary Prevention Expenditures by Institute of Medicine (IOM) Categories

The state or jurisdiction must complete SABG Table 5b if it chooses to report SUD primary prevention activities utilizing the IOM Model of Universal, Selective and Indicated. Indicate how much funding supported each of the IOM classifications of Universal, Selective, or Indicated. Include all funding sources (e.g., Centers for Disease Control and Prevention Block Grant, foundations). For detailed instructions, refer to those in the Block Grant Application System (BGAS).

Plan Table 5b: SABG Primary Prevention Planned Expenditures by IOM Category
Planning Period Start Date: 10/1/2019 Planning Period Start Date: 9/30/2021
Activity	FFY 2020 SA Block Grant Award	FFY 2021 SA Block Grant Award	COVID-19 Award¹	ARP Award²
Universal Direct	$	$	$	$
Universal Indirect	$	$	$	$
Selective	$	$	$	$
Indicated	$	$	$	$
Column Total	$	$	$	$
Total SABG Award³	$	$	$	$
Planned Primary Prevention Percentage	%	%	%	%

¹The 24-month expenditure period for the COVID-19 Relief Supplemental funding is March 15, 2021 - March 14, 2023. Per the instructions, the planning period for the standard SABG expenditures for the FFY 2021 SABG Award is October 1, 2020 - September 30, 2021. For purposes of this table, all COVID-19 Relief Supplemental expenditures between March 15, 2021 and September 30, 2021 should be entered in this column.

³Total SABG Award is populated from Table 4 - SABG Planned Expenditures

SABG Table 5c (Requested) - SABG Primary Prevention Targeted Priorities

The purpose of the first table is for the state or jurisdiction to identify the substance and/or categories of substances it identified through its needs assessment and then addressed with primary prevention set-aside dollars from the FY 2016 SABG NoA. The purpose of the second table is to identify each special population the state or jurisdiction selected as a priority for primary prevention set-aside expenditures.

	SABG Award	COVID-19 Award¹	ARP Award²
Targeted Substances
Alcohol
Tobacco
Marijuana
Prescription Drugs
Cocaine
Heroin
Inhalants
Methamphetamine
Synthetic Drugs (e.g., Bath salts, Spice, K2)

Instructions: In the table below, identify the special population categories the state BG plans to target with primary prevention set-aside dollars.

Targeted Populations
Students in College
Military Families
LGBTQ
American Indians/Alaska Natives
African American
Hispanic
Homeless
Native Hawaiian/Other Pacific Islanders
Asian
Rural
Underserved Racial and Ethnic Minorities

Plan Table #6

Proposed Categories for Expenditures for System Development/Non-Direct-Service Activities

Expenditures in the following categories of activities may involve the time of State or sub-State personnel, or may be funded through contracts, grants, or agreements with other entities. Expenditures may come from the administrative funds and/or program funds (but may not include the HIV set-aside funds). Please utilize the following categories to describe the types of expenditures your state supports with BG funds, and if the preponderance of the activity fits within a category.

We understand that a particular activity may cross categories, but try to identify the primary purpose or goal of the activity. For example, a state may utilize BG funds to train personnel to conduct fidelity assessments of evidence-based practices. While this could fall under either training/education and/or quality assurance/improvement – the primary purpose is to assure the implementation of EBPs, so that expenditure would most likely be captured under quality assurance/improvement.

Information systems – This includes collecting and analyzing treatment data as well as prevention data under the SABG in order to monitor performance and outcomes. Costs for electronic health records and other health information technology also fall under this category.

Infrastructure Support – This includes activities that provide the infrastructure to support services but for which there are no individual services delivered. Examples include the development and maintenance of a crisis-response capacity, including hotlines, mobile crisis teams, web-based check-in groups (for medication, treatment, re-entry follow-up), drop-in centers, and respite services.

Partnerships, community outreach, and needs assessment – This includes state, regional, and local personnel salaries prorated for time and materials to support planning meetings, information collection, analysis, and travel. It also includes the support for partnerships across state and local agencies, and tribal governments. Community/network development activities, such as marketing, communication, and public education, and including the planning and coordination of services, fall into this category, as do needs-assessment projects to identify the scope and magnitude of the problem, resources available, gaps in services, and strategies to close those gaps.

Planning Council Activities – This includes those supports for the performance of a Mental Health Planning Council under the MHBG, a combined Behavioral Health Planning Council, or (OPTIONAL) Advisory Council for the SABG.

Quality assurance and improvement – This includes activities to improve the overall quality of services, including those activities to assure conformity to acceptable professional standards, adaptation and review of implementation of evidence-based practices, identification of areas of technical assistance related to quality outcomes, including feedback. Administrative agency contracts to monitor service-provider quality fall into this category, as do independent peer-review activities.

Research and evaluation – This includes performance measurement, evaluation, and research, such as services research and demonstration projects to test feasibility and effectiveness of a new approach as well as the dissemination of such information.

Training and education– This includes skill development and continuing education for personnel employed in local programs as well as partnering agencies, as long as the training relates to either substance use disorder service delivery (prevention, treatment and recovery) for SABG and services to adults with SMI or children with SED for MHBG. Typical costs include course fees, tuition, and expense reimbursements to employees, trainer(s) and support staff salaries, and certification expenditures.

	Non-Direct-Services/System Development
	SABG/MHBG Table 6
	State Identifier:
	Report Period- From: To:
Activity		A. MHBG	B. SABG Treatment	C. SABG Prevention	D. SABG Integrated ⁰
1. Information Systems		$	$	$	$
2. Infrastructure Support		$	$	$	$
3. Partnerships, community outreach, and needs assessment		$	$	$	$
4. Planning Council Activities (MHBG required, SABG optional)		$	$	$	$
5. Quality assurance and improvement		$	$	$	$
6. Research and Evaluation		$	$	$	$
7. Training and Education		$	$	$	$
8. Total		$	$	$	$

Please enter the total amount of the block grant expended for each activity.

*Combined refers to funds both treatment and prevention portions of the SABG for overarching activities.

SABG Table 7 – State Entity Inventory

This table provides a report of the sub-recipients of SABG funds including community- and faith-based organizations which provided SUD prevention activities and treatment services, as well as intermediaries/administrative service organizations. Table 7 excludes system development/non-direct service expenditures. For detailed instructions, see those in BGAS.

Statewide Entity Inventory

SABG Table 7

State Identifier:

Report Period- From: To:

Source of Funds

SAPT Block Grant

Entity Number

I-BHS ID

(formerly I-SATS)

Area Served (Statewide or Sub- State

Planning Area)

Provider/Program Name

Street Address

City

State

Zip

All SA Block Grant Funds

Prevention (other than Primary Prevention) and

Treatment Services

Pregnant Women and Women with

Dependent Children

Primary Prevention

Early Intervention Services for HIV

Syringe Services Program

Total

Description of Calculations for MOE Tables 8a and 8b

Please provide a description of the amounts and methods used to calculate the following:

total Single State Agency (SSA) expenditures for SUD prevention and treatment as required by: a. 42 U.S.C. § 300x-30 and 45 CFR § 96.124(f)(4)
the base and, for 1994 and subsequent fiscal years, report the federal and state expenditures for services to pregnant women and women with dependent children as required by:

a. 42 U.S.C. § 300x-22(b)(1) and 45 CFR § 96.122(f)(5)(ii)(A)

SABG Table 8a - Maintenance of Effort for State Expenditures for SUD Prevention and Treatment

This Maintenance of Effort table provides a description of non-federal expenditures for authorized activities to prevent and treat substance abuse flowing through the Single State Agency (SSA) during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. (Dates given are for the FY 2017 SABG Report. For the FY 2018 SABG report, increase each year by one.)

For detailed instructions, see those in BGAS.

SABG Table 8a Total Single State Agency (SSA) Expenditures for Substance Abuse Prevention and Treatment
State Identifier:
Report Period- From: To:
Period (A)	Expenditures (B)	B1 (2014) + B2 (2015) 2 (C)
SFY 2017 (1)
SFY 2018 (2)
SFY 2019 (3)

Are the expenditure amounts reported in Column B “actual” expenditures for the fiscal years involved?

	Yes	No
SFY 2017
SFY 2018
SFY 2019

If any estimated expenditures are provided, please indicate when “actual” expenditure data will be submitted to SAMHSA:

Did the state or jurisdiction have any non-recurring expenditures as described in 42 U.S.C. § 300x-30(b) for a specific purpose which were not included in the MOE calculation? Yes No

If yes, specify the amount and the State fiscal year

Did the state or jurisdiction include these funds in previous year MOE calculations? Yes No

When did the State or Jurisdiction submit an official request to SAMHSA to exclude these funds from the MOE calculations?

SABG Table 8b - Expenditures for Services to Pregnant Women and Women with Dependent Children

This table provides a report of all statewide, non-federal funds expended on specialized treatment and related services which meet the SABG requirements for pregnant women and women with dependent children during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. (Dates given are for the FY 2017 SABG Report. For the FY 2018 SABG Report, increase each year (other than the base year) by one.)

For detailed instructions, see those in BGAS.

Expenditures for Services to Pregnant Women and Women with Dependent Children
SABG Table 8b
State Identifier:
Report Period- From: To:
eriod	Total Women’s Base (A)	Total Expenditures (B)
1994
2017
2018
2019

Populations and Services Report

States are required to provide information regarding individuals that are served by the SSA in SABG Tables 9 through 13.

SABG Table 9 - Prevention Strategy Report This table requires additional information (pursuant to Section 1929 of Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. § 300x-29) about the primary prevention activities conducted by the entities listed on SABG Table 7, State Entity Inventory, Column D. It seeks further information on the specific strategies and activities being funded by the principal agency of the state which address the sub-populations at risk for alcohol, tobacco, and other drug (ATOD) use/abuse.

SABG Table 10 - Treatment Utilization Matrix This table is intended to capture the count of persons with initial admissions and subsequent admission(s) to an episode of care (as defined in the Behavioral Health Services Information System (BHSIS), formerly known as the Drug and Alcohol Services Information System (DASIS), Treatment Episode Data Set (TEDS) standards (see TEDS data) during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds.

SABG Table 11a - Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use. This table provides an aggregate profile of the unduplicated number of admissions and persons for services funded through the SABG during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. States are to provide this information on all programs by age, gender, and race/ethnicity. States are to report whether the values reported come from a client-based system(s) with unique client identifiers.

SABG Table 11b – COVID-19 Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use. This table provides an aggregate profile of the unduplicated number of admissions and persons for services funded with COVID-19 Relief Supplement funds during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. States are to provide this information on all programs by age, gender, and race/ethnicity. States are to report whether the values reported come from a client- based system(s) with unique client identifiers.

SABG Table 11c – Sex, Sexual Orientation, and Gender Identity Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use. This table provides an aggregate profile of the unduplicated number of admissions and persons for services funded through the SABG during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds by sex, sexual orientation, and gender identity. States are to report whether the values reported come from a client- based system(s) with unique client identifiers.

SABG Table 12 – SABG Designated States and Early Intervention Services Regarding the Human Immunodeficiency Virus. This table requires designated states as defined in section 1924(b)(2) of Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. § 300x-24(b)(2)), to provide information on Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV) provided during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds.

SABG Table 13 - Charitable Choice This table requires states to provide information regarding compliance with section 1955 of Title XIX, Part B, Subpart III of the PHS Act (42 U.S.C. § 300x-65) and the Charitable Choice Provisions and Regulations; Final Rule (42 CFR Part 54) during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds.

Each section of this table requires that the state respond appropriately to identify the manner in which they have complied with the requirements related to authorizing legislation and implementing regulation. States should report on the number of clients referred, due to religious objection, from faith and community-based programs to appropriate alternative providers. If no alternate referrals were made, enter zero.

SABG Table 9 - Prevention Strategy Report

This table requires additional information (pursuant to Section 1929 of Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C.§ 300x- 29) about the primary prevention activities conducted by the entities listed on SABG Table 7. For detailed instructions, see those in BGAS.Prevention Strategy Report Risk-Strategies
SABG Table 9
Report Period- From: To:
State Identifier
Column A (Risks)	Column B (Strategies)	Column C (Providers)
Children of Substance Abusers [1]
Pregnant Women / Teens [2]
Drop-Outs [3]
Violent and Delinquent Behavior [4]
Mental Health Problems [5]
Economically Disadvantaged [6]
Physically Disabled [7]
Abuse Victims [8]
Already Using Substances [9]
Homeless and/or Runaway Youth [10]
Other, Specify [11]

SABG Table 10 – Treatment Utilization Matrix

This table is intended to capture the count of persons with initial admissions and subsequent admission(s) to an episode of care. For detailed instructions, see those in BGAS.

For detailed instructions, see those in BGAS.

Expenditure Period Start Date: 7/1/2020 Expenditure Period End Date: 6/30/2021

Level of Care	SABG Number of Admissions ≥ Number of Persons Served			COVID-19 Number of Admissions ≥ Number of Persons Served^⁰			SABG Costs per Person (C, D & E)					COVID-19 Costs per Person (C, D & E)¹
	Number of Admissions (A)	Number of Persons Served (B)		Number of Admissions (A)		Number of Persons Served (B)	Mean Cost of Services (C)		Median Cost of Services (D)	Standard Deviation of Cost (E)	Mean Cost of Services (C)		Median Cost of Services (D)		Standard Deviation of Cost (E)
DETOXIFICATION (24-HOUR CARE)
1. Hospital Inpatient	1778		939	1411	877
2. Free-Standing Residential
REHABILITATION/RESIDENTIAL
3. Hospital Inpatient	0 2789		4066	0 2724	4066
4. Short-term (up to 30 days)
5. Long-term (over 30 days)
AMBULATORY (OUTPATIENT)
6. Outpatient	13591 3426		0	13591 3282	0			$0				$0
7. Intensive Outpatient
8. Detoxification														$0
OUD MEDICATION ASSISTED TREATMENT
9. OUD Medication-Assisted Detoxification⁰	0		14728	0	14728			$0				$0		$0
10. OUD Medication-Assisted Treatment Outpatient⁰

SABG Table 11 - Unduplicated Count of Persons Served for Alcohol and Other Drug Use

This table provides an aggregate profile of the unduplicated number of admissions and persons for services funded through the SABG. For detailed instructions, see those in BGAS.

SABG Table 11a

Report Period- From: To::

State Identifier:

Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State Funded Services by Age, Sex and Race/Ethnicity

Sex and Race/Ethnicity

Age

A. Total

B. White

C. Black or African American

D. Native Hawaiian/ Other Pacific Islander

E. Asian

F. American Indian/Alaska n Native

G. More Than One Race Reported

H. Unknown

I. Not Hispanic or Latino

J. Hispanic or Latino

1. 17 and under

2. 18-24

3. 25-44

4. 45-64

5. 65 and

over

5. Total

7. Pregnant

Women

Numbers of Persons Served who were admitted in a Period Prior to the 12 month

reporting Period

Number of persons served

outside of the levels of care described on SABG Table 10

Are the values reported in this table generated from a

client based system with unique client identifiers?

Yes

SABG Table 11b

Report Period- From:

To::

State Identifier:

Sex and Race/Ethnicity

Age

A. Total

B. White

C. Black or African American

D. Native Hawaiian/ Other Pacific Islander

E. Asian

F. American Indian/Alaska n Native

G. More Than One Race Reported

H. Unknown

I. Not Hispanic or Latino

J. Hispanic or Latino

1. 17 and under

2. 18-24

3. 25-44

4. 45-64

5. 65 and

over

5. Total

7. Pregnant

Women

Numbers of Persons Served who were admitted in a Period Prior to the 12 month

reporting Period

Number of persons served

outside of the levels of care described on SABG Table 10

Are the values reported in this table generated from a

client based system with unique client identifiers?

Yes

SABG Table 11c

Report Period- From: To:

State Identifier:

Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State Funded Services by Sex, Sexual Orientation, and Gender Identity

AGE

Male

Female

Transgender Man /Transman /Female-To-Man

Transgender Woman/ Transwoman/ Male-To-Female

Genderqueer/ Gender Non-Conforming/ Neither Exclusively Male or Female

Additional Gender Category (or Other)

Straight or Heterosexual

Gay or Lesbian

Bisexual

Queer, Pansexual, and/or Questioning

Something Else? Please Specify

17 and Under

18-24

25-44

45-64

65 and over

TOTAL

SABG Table 12 - SABG Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV) in Designated States

For detailed instructions, see those in BGAS.

SABG Table 12
Report Period- From: To::
State Identifier
Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV)
1. Number of EIS/HIV projects among SABG sub-recipients in the state:	Statewide:	Rural:
2. Total number of individuals tested through SABG sub-recipient EIS/HIV projects:
3. Total number of HIV tests conducted with SABG EIS/HIV funds:
4. Total number of tests that were positive for HIV:
5. Total number of individuals who prior to the 12-month reporting period were unaware of their HIV infection:
6. Total number of HIV-infected individuals who were diagnosed and referred into treatment and care during the 12-month reporting period
Identify barriers, including state laws and regulations, that exist in carrying out HIV testing services:

SABG Table 13 - Charitable Choice – Required

Under Charitable Choice Provisions; Final Rule (42 CFR Part 54), states, local governments, and religious organizations, such as SAMHSA grant recipients, must: (1) ensure that religious organizations that are providers provide to all potential and actual program beneficiaries (services recipients) notice of their right to alternative services; (2) ensure that religious organizations that are providers refer program beneficiaries to alternative services; and (3) fund and/or provide alternative services. The term “alternative services” means services determined by the state to be accessible and comparable and provided within a reasonable period of time from another substance abuse provider (“alternative provider”) to which the program beneficiary (services recipient) has no religious objection. The purpose of this table is to document how the state is complying with these provisions.

Notice to Program Beneficiaries – Check all that apply:

Used model notice provided in final regulations.

Used notice developed by state (please attach a copy to the Report)

State has disseminated notice to religious organizations that are providers.

State requires these religious organizations to give notice to all potential beneficiaries.

Referrals to Alternative Services – Check all that apply:

State has developed specific referral system for this requirement.

State has incorporated this requirement into existing referral system(s).

SAMHSA’s Behavioral Health Treatment Locator is used to help identify providers.

Other networks and information systems are used to help identify providers.

State maintains record of referrals made by religious organizations that are providers.

Enter the total number of referrals to other substance abuse providers (“alternative providers”) necessitated by religious objection, as defined above, made during the State fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. Provide the total only. No information on specific referrals is required. If no alternative referrals were made, enter zero.

Provide a brief description (one paragraph) of any training for local governments and/or faith-based and/or community organizations that are providers on these requirements.

Performance Data and Outcomes

SAMHSA is interested in demonstrating program accountability and efficacy through the National Outcome Measures (NOMs). The NOMs are intended to document the performance of federally supported programs and systems of care.

SABG Table 14 Employment/Education Status This table describes the status of adult clients served by the public SUD treatment service systems in terms of employment and education status. The Employment\Education Status Form seeks information on clients who are employed or who are students (full-time or part-time) (prior 30 days) at admission and discharge.

SABG Table 15 Stability of Housing This table requests information regarding the number of individuals in a stable living environment as collected by the most recent assessment in the reporting period. Specifically, information is collected on the individual’s last known living situation.

SABG Table 16 Criminal Justice Involvement This table requests information regarding the clients’ involvement in the criminal justice system. Specifically, the table requests information to measure the change in number of arrests over time.

SABG Table 17 Change in Abstinence - Alcohol Use This table seeks information regarding alcohol abstinence. Specifically, information is collected on the number of clients with no alcohol use (all clients regardless of primary problem) at admission and discharge.

SABG Table 18 Change in Abstinence - Other Drug Use This table collects information regarding clients’ change in abstinence with drugs of abuse other than alcohol. This table seeks to collect information on clients with no other drug use (all clients regardless of primary problem) at admission and discharge.

SABG Table 19 Change in Social Support of Recovery This table seeks to measure the change in clients’ social support of recovery. Specifically, this form collects information regarding the number of clients participating in self-help groups at admission and discharge.

SABG Table 20 Retention This table collects information regarding retention. Specifically, this table collects information regarding the length of stay of clients completing treatment.

SABG Table 20 Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure: 30 Day Use. This table seeks information regarding 30 day use of alcohol, tobacco and other drugs.

SABG Table 22 Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure: Perception of Risk/Harm of Use. This table seeks information regarding the individuals’ perceived risk of harming themselves with alcohol, tobacco and other drugs.

SABG Table 23 Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Age of First Use. This table seeks information regarding the age of first use of alcohol, cigarettes and other drugs.

SABG Table 24 Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Perception of Disapproval/Attitudes. This table seeks information regarding the general public perception or attitude regarding use of alcohol, cigarettes and other drugs.

SABG Table 25 Employment/Education; Measure: Perception of Workplace Policy. This table reports the percent of individuals who would be more likely to work for an employer conducting random drug and alcohol tests.

SABG Table 26 Employment/Education; Measure: Average Daily School Attendance Rate. This table collects information regarding the average daily school attendance.

SABG Table 27 Crime and Criminal Justice; Measure: Alcohol-Related Traffic Fatalities. This table collects information regarding the number of alcohol-related traffic fatalities divided by the total number of traffic fatalities and multiplied by 100.

SABG Table 28 Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests. This table collects information regarding alcohol- and drug-related arrests.

SABG Table 29 Social Connectedness; Measure: Family Communications around Drug and Alcohol Use. This table provides information regarding the percent of youth reporting having talked with a parent and the percent of parents reporting that they have talked to their child around alcohol and drug use.

SABG Table 30 Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or Listening to a Prevention Message. This table collects information regarding the percent of youth reporting having been exposed to prevention message.

SABG Table 31 Individual-Based Programs and Strategies; Measure: Number of Persons Served By Age, Gender, Race, and Ethnicity. This table provides information on the number of persons served by individual-based programs and strategies. This includes practices and strategies with identifiable goals designed to change behavioral outcomes among a definable population or within a definable geographic area.

SABG Table 32 Population-Based Programs and Strategies; Measure: Number of Persons Served By Age, Gender, Race, and Ethnicity. This table provides information regarding the number of persons by age, gender, race, and ethnicity that participated in population-based programs.

Population-based programs and strategies include planned and deliberate goal-oriented practices, procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps subject to monitoring and modification.

SABG Table 33 Number of Persons Served by Type of Intervention. This table seeks to measure information on access and capacity of intervention programs. Specifically, this form collects information on the number of persons served by type of Intervention. Interventions include activities, practices, procedures, processes, programs, services, and strategies.

SABG Table 34 Number of Evidence-Based Programs by Types of Intervention. This table collects information on the number of evidence-based programs and strategies by type of intervention.

SABG Table 35 Number of Evidence-based Programs and Strategies, and Total SABG Funds Spent on Evidence-Based Programs/ Strategies.

SABG Table 14 – TREATMENT PERFORMANCE MEASURE

Shape4

Employment\Education Status – Clients employed or student (full-time or part-time) (prior 30 days) at admission vs. discharge	Admission Clients ^(T1⁾	Discharge Clients ^(T2⁾
Number of clients employed or student (full-time and part-time) [numerator]
Total number of clients with non-missing values on employment\student status [denominator]
Percent of clients employed or student (full-time and part-time)

EMPLOYMENT\EDUCATION STATUS (From Admission to Discharge) Most recent year for which data are available:

State Description of Employment\Education Status Data Collection (SABG Table 15)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Employment\Education Data Collection (SABG Table 15): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for SABG Table 15 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify
EPISODE OF CARE	How is the admission/discharge basis defined for SABG Table 15 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit Other Specify _
DISCHARGE DATA COLLECTION	How was discharge data collected for SABG Table 15 (select all that apply) Not applicable, data reported on form is collected at time period other than discharge→ Specify: In-treatment data days post-admission, OR □ Follow-up data (specify) months Post- □ admission □ discharge □ other Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment Discharge records are not collected for approximately % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table 15 (select all that apply): Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider- entity-specific unique ID No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing employment\student status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

SABG Table 15–TREATMENT PERFORMANCE MEASURE

STABILITY OF HOUSING (From Admission to Discharge)

Most recent year for which data are available:

Clients living in a stable living situation (prior 30 days) at admission vs. discharge	Admission Clients ^(T1⁾	Discharge Clients ^(T2⁾
Number of clients living in a stable situation [numerator]
Total number of clients with non-missing values on living arrangements [denominator]
Percent of clients in a stable living situation

State Description of Stability in Housing Data Collection (SABG Table 14)

STATE CONFORMANCE TO INTERIM STANDARD

State Description of Stability in Housing Data Collection (SABG Table 15):

States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.

DATA SOURCE

What is the source of data for SABG Table 15 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify

EPISODE OF CARE

How is the admission/discharge basis defined for SABG Table 15 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days

Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is

on the last date of service in a Program/Service Delivery Unit

Other Specify _

DISCHARGE DATA COLLECTION

How was discharge data collected for SABG Table 15 (select all that apply)

Not applicable, data reported on form is collected at time period other than discharge→

Specify:

In-treatment data days post-admission, OR □ Follow-up data (specify) months Post-
admission □ discharge □ other
Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment
Discharge records are not collected for approximately % of clients who were admitted

for treatment

RECORD LINKING

Was the admission and discharge data linked for SABG Table 15 (select all that apply):

Yes, all clients at admission were linked with discharge data using an Unique Client

Identifier (UCID)

Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity- specific unique ID

No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.

IF DATA IS UNAVAILABLE

If data is not reported, why is the state unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but

utilizes a different measure.

DATA PLANS IF DATA IS NOT AVAILABLE

State must provide time-framed plans for capturing criminal justice involvement status data on

all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

SABG Table 16– TREATMENT PERFORMANCE MEASURE

Shape7

Clients without arrests (any charge) (prior 30 days) at admission vs. discharge	Admission Clients ^(T1⁾	Discharge Clients ^(T2⁾
Number of Clients without arrests [numerator]
Total number of clients with non-missing values on arrests [denominator]
Percent of clients without arrests

CRIMINAL JUSTICE INVOLVEMENT (From Admission to Discharge) Most recent year for which data are available:

State Description of Criminal Involvement Data Collection (SABG Table 16)

STATE CONFORMANCE TO INTERIM STANDARD

State Description of Criminal Involvement Data Collection (SABG Table 16):

States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.

DATA SOURCE

What is the source of data for SABG Table 16 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify

EPISODE OF CARE

How is the admission/discharge basis defined for SABG Table 16 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days

Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit
Other Specify _

DISCHARGE DATA COLLECTION

How was discharge data collected for SABG Table 16 (select all that apply)

Not applicable, data reported on form is collected at time period other than discharge→

Specify:

In-treatment data days post-admission, OR □ Follow-up data (specify) months Post-
admission □ discharge □ other
Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment
Discharge records are not collected for approximately % of clients who were admitted for treatment

RECORD LINKING

Was the admission and discharge data linked for SABG Table 16 (select all that apply):

Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID)

No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.

IF DATA IS UNAVAILABLE

If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but

utilizes a different measure.

DATA PLANS IF DATA IS NOT AVAILABLE

State must provide time-framed plans for capturing criminal justice involvement status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs

and estimates of cost.

SABG Table 17– PERFORMANCE MEASURE

Shape9

Alcohol Abstinence – Clients with no alcohol use (all clients regardless of primary problem) (use Alcohol Use in last 30 days field) at admission vs. discharge.	Admission Clients ^(T1⁾	Discharge Clients ^(T2⁾
Number of clients abstinent from alcohol [numerator]
Total number of clients with non-missing values on “used any alcohol” variable [denominator]
Percent of clients abstinent from alcohol
(1) If State does not have a "used any alcohol" variable, calculate instead using frequency of use variables for all primary, secondary, or tertiary problem codes in which the coded problem is Alcohol (e.g. ,TEDS Code 01)

CHANGE IN ABSTINENCE – ALCOHOL USE (From Admission to Discharge) Most recent year for which data are available:

State Description of Alcohol Use Data Collection (SABG Table 17)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Alcohol Use Data Collection (SABG Table 17): State should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for SABG Table 17 (select all that apply): Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source Administrative data source □ Other Specify
EPISODE OF CARE	How is the admission/discharge basis defined for SABG Table 17 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit Other Specify _
DISCHARGE DATA COLLECTION	How was discharge data collected for SABG Table 17 (select all that apply) Not applicable, data reported on form is collected at time period other than discharge→ Specify: In-treatment data days post-admission, OR □ Follow-up data (specify) months Post- admission □ discharge □ other Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment Discharge records are not collected for approximately % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for SABG Table 17 (select all that apply): Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity- specific unique ID No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing abstinence - alcohol use status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

SABG Table 18 – PERFORMANCE MEASURE

Shape10

Drug Abstinence – Clients with no drug use (all clients regardless of primary problem) (use Any Drug Use in last 30 days field) at admission vs. discharge.	Admission Clients ^(T1⁾	Discharge Clients ^(T2⁾
Number of Clients abstinent from illegal drugs [numerator]
Total number of clients with non-missing values on “used any drug” variable [denominator] *
Percent of clients abstinent from drugs

CHANGE IN ABSTINENCE -- OTHER DRUG USE (From Admission to Discharge) Most recent year for which data are available:

*If State does not have a "used any drug" variable, calculate instead using frequency of use variables for all primary, secondary, or tertiary problem codes in which the coded problem is Drugs (e.g., TEDS Codes 01-04)

State Description of Other Drug Use Data Collection (SABG Table 18)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Other Drug Use Data Collection (SABG Table 18): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for SABG Table 18 (select all that apply): Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source Administrative data source □ Other Specify
EPISODE OF CARE	How is the admission/discharge basis defined for SABG Table 18 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit Other Specify _
DISCHARGE DATA COLLECTION	How was discharge data collected for SABG Table 18 (select all that apply) Not applicable, data reported on form is collected at time period other than discharge→ Specify: In-treatment data days post-admission, OR □ Follow-up data (specify) months Post- admission □ discharge □ other Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment Discharge records are not collected for approximately % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for SABG Table 18 (select all that apply): Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity- specific unique ID No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing abstinence – drug use status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

SABG Table 19 – PERFORMANCE MEASURE

CHANGE IN SOCIAL SUPPORT OF RECOVERY (From Admission to Discharge)

Most recent year for which data are available:

Social Support of Recovery – Clients participating in self-help groups (e.g., AA, NA, etc.) (prior 30 days) at admission vs. discharge	Admission Clients ^(T1⁾	Discharge Clients ^(T2⁾
Number of clients participating in self-help (AA NA meetings attended, etc.) [numerator]
Total number of Admission and Discharge clients with non-missing values on self- help activities [denominator]
Percent of clients participating in self-help activities

State Description of Social Support of Recovery Data Collection (SABG Table 19)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Social Support of Recovery Data Collection (SABG Table 19): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for SABG Table 19 (select all that apply): Client self-report □ Client self-report confirmed by another source→ collateral source □ Administrative data source Other Specify
EPISODE OF CARE	How is the admission/discharge basis defined for SABG Table 19 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit Other Specify _
DISCHARGE DATA COLLECTION	How was discharge data collected for SABG Table 19 (select all that apply) Not applicable, data reported on form is collected at time period other than discharge→ Specify: In-treatment data days post-admission, OR □ Follow-up data (specify) months Post- □ admission □ discharge □ other Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment Discharge records are not collected for approximately % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for SABG Table 19 (select all that apply): Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing self-help participation status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

SABG Table 20: RETENTION

Length of Stay (in Days) of Clients Completing Treatment Most recent year for which data are available:

LENGTH OF STAY
Level of Care	Av e r a g e ( Me a n)	Me di an ( Me di an)	Int erqu art ile Ra ng e
Detoxification (24-hour care)
1. Hospital Inpatient
2. Free-Standing Residential
Rehabilitation/Residential
3. Hospital Inpatient
4. Short-term (up to 30 days)
5. Long-term (over 30 days)
Ambulatory (Outpatient)
6. Outpatient
7. Intensive Outpatient
8. Detoxification
OUD Medication-Assisted Treatment
9. OUD Medication-Assisted Detoxification⁰
10. OUD Medication-Assisted Treatment Outpatient⁰

Section V: Performance Indicators and Accomplishments Tables 21-36: Prevention Performance Measures

Introduction

The National Outcome Measures (NOMs) are a set of domains and measures that the Substance Abuse and Mental Health Services Administration (SAMHSA) uses to accomplish its vision and to meet all of its federal reporting requirements, thus reducing burden and redundancy for grantees.

The NOMs Data Collection and Reporting tables are to be completed as part of the state's annual SABG application. For Tables 21-25 and 27-30, the compliance year is calendar year (CY) 2017 (note that pre-populated NOMs from the National Survey on Drug Use and Health (NSDUH) reflect pooled data from CYs 2016-2017. For substance abuse prevention NOMs Table 26, the compliance year is School Year 2017.

For purposes of this section, unless otherwise noted, the term "state" refers to states, territories, and the one Native American tribe that receive SABG funding.

Pre-populated Data

CSAP and the states have agreed that the state-level reporting requirement for the NOMs listed in Tables 21-30 will be fulfilled through the use of extant data from sources including the National Survey on Drug Use and Health (NSDUH), the Fatality Analysis Reporting System (FARS) of the National Highway Traffic Safety Administration, the Uniform Crime Report (UCR) of the Federal Bureau of Investigation, and the National Center for Education Statistics (NCES) of the U.S. Department of Education. These pre-populated state-level NOMs will meet most of the state-level NOMs reporting requirements for the prevention portion of the SABG funding. These data will be pre-populated into the data tables by CSAP.

NOMs Domain - Reduced Morbidity Abstinence from Drug Use/Alcohol Use

Table 21: 30-Day Use
Table 22: Perception of Risk/Harm of Use
Table 23: Age of First Use
Table 24: Perception of Disapproval/Attitudes

NOMs Domain - Employment/Education

Table 25: Perception of Workplace Policy
Table 26: Average Daily School Attendance Rate

NOMs Domain - Crime and Criminal Justice

Table 27: Alcohol-Related Traffic Fatalities
Table 28: Alcohol- and Drug-Related Arrests NOMs Domain - Social Connectedness

Table 29: Family Communications Around Drug and Alcohol Use

NOMs Domain - Retention

Table 30: Youth Seeing, Reading, Watching, or Listening to a Prevention Message

In this block grant application, pre-populated data are automatically provided to fulfill the majority of the reporting requirements.

Territories and Native American tribes for which there are no NSDUH, FARS, UCR, and/or NCES data will not be required to report on those measures on those measures, but will be encouraged to provide substitute data in Column D.

Supplemental Data

States may also wish to provide additional data related to the NOMs. The data can be included in the block grant appendix. When describing the supplemental data, states should provide any relevant Web addresses (URLs) that provide links to specific state data sources.

Column A: Measure - The SAMHSA-defined measure for the domain listed.

Source Survey Item: For Table 21-25, 29, and 30, the source is the NSDUH. For Tables 26-28 other "archival" sources are identified. The specific language used for each item is provided.
Response Option: The range of responses that are provided for the survey item.
Outcome Reported: The specific responses that are included in the calculation provided for the item.
Age: The age range for which the responses are provided.

Column C: Pre-populated Data - Pre-populated data are provided; see letter A, Pre-populated data.

Column D: Approved Substitute Data – Grantees for which there are no NSDUH, FARS, UCR and/or NCES data will be able to voluntarily enter data for the items in this column.

Substitute data is not allowed for grantees with pre-populated data.

SABG TABLE 21– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG USE/ALCOHOL USE

MEASURE: 30-DAY USE

A. Measure	B. Question/Response	C. Pre- populated Data	D. Supplemental Data, if any
1. 30-day Alcohol Use	Source Survey Item: NSDUH Questionnaire. “Think specifically about the past 30 days, that is, from [DATEFILL] through today. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used alcohol during the past 30 days.
	Ages 12–20 – CY 2016-2017
	Ages 21+ - CY 2016-2017
2. 30-day Cigarette Use	Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that is, since [DATEFILL], on how many days did you smoke part or all of a cigarette?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having smoked a cigarette during the past 30 days.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
3. 30-day Use of Other Tobacco Products	Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that is, since [DATEFILL], on how many days did you use [other tobacco products]^†?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used a tobacco product other than cigarettes during the past 30 days, calculated by combining responses to questions about individual tobacco products (cigars, smokeless tobacco, pipe tobacco).
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
4. 30-day Use of Marijuana	Source Survey Item: NSDUH Questionnaire: “Think specifically about the past 30 days, from [DATEFILL] up to and including today. During the past 30 days, on how many days did you use marijuana or hashish?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used marijuana or hashish during the past 30 days.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
5. 30-day Use of Illicit Drugs Other Than Marijuana	Source Survey Item: NSDUH Questionnaire: “Think specifically about the past 30 days, from [DATEFILL] up to and including today. During the past 30 days, on how many days did you use [any other illegal drug]^‡?” Outcome Reported: Percent who reported having used illegal drugs other than marijuana or hashish during the past 30 days, calculated by combining responses to questions about individual drugs (heroin, cocaine, hallucinogens, inhalants, methamphetamine, and misuse of prescription drugs).
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017

^† NSDUH asks separate questions for each tobacco product. The number provided combines responses to all questions about tobacco products other than cigarettes.

^‡ NSDUH asks separate questions for each illegal drug. The number provided combines responses to all questions about illegal drugs other than marijuana or hashish.

SABG TABLE 22– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG USE/ALCOHOL USE

MEASURE: PERCEPTION OF RISK/HARM OF USE

A. Measure	B. Question/Response	C. Pre- populated Data	D. Supplemental Data, if any
1. Perception of Risk From Alcohol	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–20 - CY 2016-2017
	Ages 21+ - CY 2016-2017
2. Perception of Risk From Cigarettes	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they smoke one or more packs of cigarettes per day?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
3. Perception of Risk From Marijuana	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they smoke marijuana once or twice a week?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017

SABG TABLE 23– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG USE/ALCOHOL USE

MEASURE: AGE OF FIRST USE

A. Measure	B. Question/Response	C. Pre- populated Data	D. Supplemental Data, if any
1. Age at First Use of Alcohol	Source Survey Item: NSDUH Questionnaire: “Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink.” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of alcohol.
	Ages 12–20 - CY 2016-2017
	Ages 21+ - CY 2016-2017
2. Age at First Use of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you smoked part or all of a cigarette?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of cigarettes.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
3. Age at First Use of Tobacco Products Other Than Cigarettes	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used [any other tobacco product]^†?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of tobacco products other than cigarettes.
	Ages 12–17 - CY 2016-2017
	Ages 18+ CY 2016-2017
4. Age at First Use of Marijuana or Hashish	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used marijuana or hashish?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of marijuana or hashish.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
5. Age at First Use of Heroin	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used heroin?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of heroin.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017
6. Age at First Misuse of Prescription Pain Relievers Among Past Year Initiates	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used [specific pain reliever]^‡ in a way a doctor did not direct you to use it?” [Response option: Write in age at first use.] Outcome Reported: Average age at first misuse of prescription pain relievers among those who first misused prescription pain relievers in the last 12 months.
	Ages 12–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017

^† The question was asked about each tobacco product separately, and the youngest age at first use was taken as the measure.

^‡ The question was asked about each drug in this category separately, and the youngest age at first use was taken as the measure.

SABG TABLE 24– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG USE/ALCOHOL USE

MEASURE: PERCEPTION OF DISAPPROVAL/ATTITUDES

A. Measure	B. Question/Response	C. Pre- populated Data	D. Supplemental Data, if any
1. Disapproval of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age smoking one or more packs of cigarettes a day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
1. Disapproval of Cigarettes	Ages 12–17 - CY 2016-2017
2. Perception of Peer Disapproval of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How do you think your close friends would feel about you smoking one or more packs of cigarettes a day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent reporting that their friends would somewhat or strongly disapprove.
2. Perception of Peer Disapproval of Cigarettes	Ages 12–17 - CY 2016-2017
3. Disapproval of Using Marijuana Experimentally	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age trying marijuana or hashish once or twice?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
3. Disapproval of Using Marijuana Experimentally	Ages 12–17 - CY 2016-2017
4. Disapproval of Using Marijuana Regularly	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age using marijuana once a month or more?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
4. Disapproval of Using Marijuana Regularly	Ages 12–17 - CY 2016-2017
5. Disapproval of Alcohol	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
5. Disapproval of Alcohol	Ages 12–20 - CY 2016-2017

SABG TABLE 25– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: EMPLOYMENT/EDUCATION MEASURE: PERCEPTION OF WORKPLACE POLICY

A. Measure	B. Question/Response	C. Pre- populated Data	D. Supplemen tal Data, if any
Perception of Workplace Policy	Source Survey Item: NSDUH Questionnaire: “Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you?” [Response options: More likely, less likely, would make no difference] Outcome Reported: Percent reporting that they would be more likely to work for an employer conducting random drug and alcohol tests.
	Ages 15–17 - CY 2016-2017
	Ages 18+ - CY 2016-2017

SABG TABLE 26– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: EMPLOYMENT/EDUCATION MEASURE: AVERAGE DAILY SCHOOL ATTENDANCE RATE

Measure

Source

Pre- populated Data

Supplemen tal Data, if any

Average Daily School Attendance Rate

Source: National Center for Education Statistics, Common Core of Data: The National Public Education Finance Survey available for download at http://nces.ed.gov/ccd/stfis.asp

Measure calculation: Average daily attendance (NCES defined) divided by total enrollment and multiplied by 100.

CY 2017

SABG TABLE 27 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: CRIME AND CRIMINAL JUSTICE MEASURE: ALCOHOL-RELATED TRAFFIC FATALITIES

Measure

Source

Pre- populated Data

Supplemental Data, if any

Alcohol-Related Traffic Fatalities

Source: National Highway Traffic Safety Administration Fatality Analysis Reporting System

Measure calculation: The number of alcohol-related traffic fatalities divided by the total number of traffic fatalities and multiplied by 100.

CY 2017

SABG TABLE 28– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: CRIME AND CRIMINAL JUSTICE MEASURE: ALCOHOL- AND DRUG-RELATED ARRESTS

Measure

Source

Pre- populated Data

Supplemental Data, if any

Alcohol- and Drug-Related Arrests

Source: Federal Bureau of Investigation Uniform Crime Reports Measure calculation: The number of alcohol- and drug-related arrests divided by the total number of arrests and multiplied by 100.

Forms P8 and P9 OMB No. 0930-0080

CY 2017

SABG TABLE 29 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: SOCIAL CONNECTEDNESS MEASURE: FAMILY COMMUNICATIONS AROUND DRUG AND ALCOHOL USE

A. Measure	B. Question/Response	C. Pre- populated Data	D. Supplemental Data, if any
1. Family	Source Survey Item: NSDUH Questionnaire: “Now think about the
Communications	past 12 months, that is, from [DATEFILL] through today. During
Around Drug and	the past 12 months, have you talked with at least one of your parents
Alcohol Use	about the dangers of tobacco, alcohol, or drug use? By parents, we
(Youth)	mean either your biological parents, adoptive parents, stepparents, or
	adult guardians, whether or not they live with you.” [Response
	options: Yes, No]
	Outcome Reported: Percent reporting having talked with a parent.
	Ages 12–17 - CY 2016-2017
2. Family	Source Survey Item: NSDUH Questionnaire: “During the past 12
Communications	months, how many times have you talked with your child about the
Around Drug and	dangers or problems associated with the use of tobacco, alcohol, or
Alcohol Use	other drugs?”^† [Response options: 0 times, 1 to 2 times, a few times,
(Parents of children	many times]
aged 12–17)	Outcome Reported: Percent of parents reporting that they have
	talked to their child.
	Ages 18+ - CY 2016-2017

^† NSDUH does not ask this question of all sampled parents. It is a validation question posed to parents of 12- to 17-year-old survey respondents. Therefore, the responses are not representative of the population of parents in a State. The sample sizes are often too small for valid reporting.

SABG TABLE 30 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: RETENTION MEASURE: PERCENTAGE OF YOUTH SEEING, READING, WATCHING, OR LISTENING TO A

PREVENTION MESSAGE

Measure

Question/Response

Pre- populated Data

Supplemental Data, if any

Exposure to Prevention Messages

Source Survey Item: NSDUH Questionnaire: “During the past 12 months, do you recall [hearing, reading, or watching an advertisement about the prevention of substance use]^†?”

Outcome Reported: Percent reporting having been exposed to prevention message.

Ages 12–17 - CY 2016-2017

^† This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within a specific context

SABG Tables 31-35 – Reporting Period

Reporting Period - Start and End Dates for Information Reported on SABG Tables 31, 32, 33, 34, and 35.

Rows 1 through 5 each correspond to a single form in the current year's application among the following five tables: 31, 32, 33, 34 and 35.

Column A: Enter the reporting period start date. Column B: Enter the reporting period end date.

The date format to be entered in columns A and B should be month/day/year, as follows.

Month: enter 2 digits (e.g. January = 01; December = 12)
Day: enter 2 digits (e.g. 1st of the month = 01; 15th of the month = 15)
Year: enter all 4 digits (e.g. 2012, 2013)

Reporting Period Start and End Dates for Information Reported on SABG Tables 31, 32, 33, 34 and 35

Please indicate the reporting period for each of the following NOMS.

Tables

A. Reporting Period Start Date

B. Reporting Period End Date

1. SABG Table 31

Individual-Based Programs and Strategies – Number of Persons Served by Age, Gender, Race, and Ethnicity

mm/dd/yyyy

2. SABG Table 32

Population-Based Programs and Strategies – Number of Persons Served by Age, Gender, Race, and Ethnicity

mm/dd/yyyy

3. SABG Table 33 (Optional)

Number of Persons Served by Type of Intervention

mm/dd/yyyy

4. SABG Table 34

Number of Evidence-Based Programs and Strategies by Type of Intervention

mm/dd/yyyy

5. SABG Table 35

Total Number of Evidence-Based Programs and Total SABG Dollars Spent on Evidence-Based Programs/Strategies

mm/dd/yyyy

General Questions Regarding Prevention NOMS Reporting

Question 1: Describe the data collection system you used to collect the NOMs data (e.g., MDS, DbB, KIT Solutions, manual process).

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Question 2: Describe how your State’s data collection and reporting processes record a participant’s race, specifically for participants who are more than one race.

Indicate whether the State added those participants to the number for each applicable racial category or whether the State added all those participants to the More Than One Race subcategory.

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SABG Table 31 – SUBSTANCE ABUSE PREVENTION Individual-Based Programs and Strategies— Number of Persons Served by Age, Gender, Race, and Ethnicity

Category	Total
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known

C. Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity Unknown
D. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native

More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)

SABG Table 32 – SUBSTANCE ABUSE PREVENTION Population-Based Programs and Strategies— Number of Persons Served by Age, Gender, Race, and Ethnicity

Category	Total
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity unknown

SABG Table 33 (Optional) – SUBSTANCE ABUSE PREVENTION

Number of Persons Served by Type of Intervention

Intervention Type	Number of Persons Served by Individual- or Population-Based Program or Strategy
Intervention Type	A. Individual-Based Programs and Strategies	B. Population-Based Programs and Strategies
1. Universal Direct
2. Universal Indirect
3. Selective
4. Indicated
5. Total

SABG Table 34 – Substance Abuse Prevention

Evidence-Based Programs and Strategies by Type of Intervention

Definition of Evidence-Based Programs and Strategies: The guidance document for the Strategic Prevention Framework State Incentive Grant, Identifying and Selection Evidence-based Interventions, provides the following definition for evidence-based programs:

Inclusion in a Federal List or Registry of evidence-based interventions

Being Reported (with positive effects) in a peer-reviewed journal

Documentation of effectiveness based on the following guidelines:

Guideline 1: The intervention is based on a theory of change that is documented in a clear logic or conceptual model; and
Guideline 2: The intervention is similar in content and structure to interventions that appear in registries and/or the peer-reviewed literature; and
Guideline 3: The intervention is supported by documentation that it has been effectively implemented in the past, and multiple times, in a manner attentive to Identifying and Selecting Evidence-Based Interventions scientific standards of evidence and with results that show a consistent pattern of credible and positive effects; and
Guideline 4: The intervention is reviewed and deemed appropriate by a panel of informed prevention experts that includes: well-qualified prevention researchers who are experienced in evaluating prevention interventions similar to those under review; local prevention practitioners; and key community leaders as appropriate, e.g., officials from law enforcement and education sectors or elders within indigenous cultures.

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SABG Table 34– SUBSTANCE ABUSE PREVENTION

Number of Evidence-Based Programs and Strategies by Type of Intervention

SABG Table 35 – Total SUBSTANCE ABUSE PREVENTION Number of Evidence Based Programs/Strategies and Total SABG Dollars Spent on SUBSTANCE ABUSE PREVENTION Evidence- Based Programs/Strategies

Total Number of Evidence-Based Programs/Strategies for IOM Category below:

Total SAPT Block Grant $Dollars Spent on evidence-based Programs/Strategies

Universal Direct

Total #

Universal Indirect

Total #

Selective

Total #

Indicated

Total #

Unspecified

Total#

Total EBPs:

Total Dollars Spent: $

0 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the “standard” SABG. Per the instructions, the “standard” SABG reporting period is state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. In this case, it is SFY 2021 (7/1/2020 – 6/30/2021). All expenditures made during SFY 2021 should be entered in Column H.

0 Prevention other than primary prevention

0 Only designated states as defined in 42 U.S.C. § 300x-24(b)(2) and 45 CFR § 96.128(b) for the applicable federal fiscal year should enter information in this row. This may include a state or states that were previously considered ?designated states? during any of the three prior federal fiscal years for which a state was applying for a grant. See EIs/HIV policy change in SABG Annual Report instructions.

0 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the “standard” SABG. Per the instructions, the “standard” SABG reporting period is state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. In this case, it is SFY 2021 (7/1/2020 – 6/30/2021). All person served using expenditures made during SFY 2021 should be entered in this table.

0 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the “standard” SABG. Per the instructions, the “standard” SABG reporting period is state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. In this case, it is SFY 2021 (7/1/2020 – 6/30/2021). All admissions and persons served during SFY 2021 using the COVID-19 award should be entered in the appropriate column. If available, the related cost per person can be entered in the appropriate columns.

0 OUD Medication-Assisted Treatment Detoxification includes hospital detoxification, residential detoxification, or ambulatory detoxification services/settings AND Opioid Medication-Assisted Treatment.

0 OUD Medication Assisted Treatment Outpatient includes outpatient services/settings AND Opioid Medication-Assisted Treatment .

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	TABLE 5A – Planned Primary Prevention Targeted Priorities – FY 2014
Author	DHHS
File Modified	0000-00-00
File Created	2021-08-24

Number of Programs and Strategies by Type of Intervention

A.

Universal Direct

B.

Universal Indirect

C.

Universal Total

D.

Selective

E.

Indicated

F.

Total

1. Number of Evidence-Based Programs and Strategies Funded

2. Total number of Programs and Strategies Funded

3. Percent of Evidence-Based Programs and Strategies