Form PDO/FR CARA Supple PDO/FR CARA Supple PDO/FR CARA Supplemental

Division of State Programs–Management Reporting Tool

(DSP-MRT)

DSP-MRT Supplement for PDO, FR-CARA, and

Related Grants

OMB No: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Contents

Administration 5

Grantee Information 6

Subrecipients 6

High-Need Communities 6

Partner Organizations 6

Assessment 8

Needs Assessment (PDO Only) 8

Accomplishments and Barriers/Challenges 8

Capacity 9

Membership 9

Advisory Council and Other Workgroup Meetings 9

Grantee Funding Resources 9

Other Resources 9

Leveraged Resources 9

Data Infrastructure 10

Training and Technical Assistance (TA) 11

Accomplishments and Barriers/Challenges 11

Planning 12

Accomplishments and Barriers/Challenges 12

Behavioral Health Disparities 13

Disparities Impact Statement 13

Population(s) Experiencing the Disparity 13

Focus and Data Gaps 13

Access to Prevention Efforts 13

Use and Reach of Prevention Efforts 13

Outcomes of Prevention Efforts 13

Accomplishments and Barriers/Challenges 13

Implementation 14

Promising Approaches and Innovations 14

Policy 14

Naloxone Access Laws 14

Good Samaritan Laws 15

High-Need Community Policies/Protocols 16

Naloxone Education and Other Opioid-Related Trainings 17

High-Need Community-Level Trainings 17

Grantee-Level Trainings 20

Training Data Collection Information 21

Naloxone Distribution Plan (PDO Only) 22

Naloxone Distribution 22

Costs 22

Kits Distributed to Partner Organizations 23

Naloxone Administration by Partner Organization 25

Other Interventions 27

Accomplishments and Barriers/Challenges 29

Evaluation 30

Evaluation Plan Upload 30

Evaluation Report 30

Other Document Upload 30

Accomplishments and Barriers/Challenges 30

Sustainability 31

Accomplishments and Barriers/Challenges 31

Overdose Outcomes 32

Grantee-Level Overdose Data 32

High-Need Community-Level Overdose Data 34

Note: This document is intended as a supplement to the Division of State Programs– Management Reporting Tool (DSP-MRT). Please refer to the DSP-MRT document where applicable.

Administration

Throughout the progress report, grantee refers to the state, tribe/tribal organization, jurisdiction, local government entity, or other entity receiving the award from the Substance Abuse and Mental Health Services Administration (SAMHSA). Community refers to the grantee’s selected High-Need communities, and subrecipient indicates the grantee’s sub-awardees funded to lead the grant in the selected communities. Some grantees refer to their subrecipients as subgrantees. Some grantees may not have a subrecipient responsible for leading the grant in each of the selected communities.

Partner organization is used to indicate any of the selected high-need community’s partners (e.g., law enforcement agencies, syringe exchange programs) that receive naloxone kits or training or that distribute naloxone to laypersons through the grant.

Note that the subrecipient may also be considered a partner organization if it will be providing these activities (e.g., distributing to laypersons) rather than simply engaging and coordinating with the other partner organizations. Exhibit 1 illustrates the involved levels and provides an example at each level.

Exhibit 1. Levels of Data Reporting

* Some grantees may not have subrecipients. Also, some subrecipients may serve more than one selected high-need community.

Grantee Information

See DSP-MRT.

Subrecipients

See DSP-MRT.

High-Need Communities

See DSP-MRT.

Partner Organizations

Use this section to add or update partner organization information for each selected high- need community. Partner organizations are the entities receiving naloxone drugs or naloxone training (e.g., law enforcement agencies) or distributing to and training laypersons (e.g., syringe exchange programs). Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

In a later section of the progress report, you will be asked to report on naloxone drugs distributed to these partner organizations, and the naloxone administration events reported by these partner organizations for this grant. Note that if the subrecipient for the selected high-need community will also be providing these activities (e.g., distributing to laypersons) rather than simply engaging and assisting the other partner organizations, you will need to enter the subrecipient as a partner organization here. Partner organization information will be carried over from one reporting period to the next.

Item	Response Options
In the SPARS data collection system, there will be an “Add” button for this section. Grantees will be able to click that button to add additional records as needed.
Partner organization name	Free text
High-Need Community	Community 1 Community 2 Etc.

Item	Response Options
Sector (Some options may not be applicable per your grant. Contact your project officer with questions.)	Corrections Courts Emergency Medical System (EMS) Emergency Medical Technician (EMT) Fire Departments Harm Reduction Agency Law Enforcement Other Social Service Organization Pharmacies Public Health Agencies Recovery Community Organization Shelters Substance Use Disorder Treatment Syringe Exchange Programs Other (specify)
Target ZIP codes of the partner organization’s service area	You will see an add button and a U.S. Postal Service ZIP code look-up link.
Target County or Counties (Alternative) (If this partner organization targets an entire county [or counties], indicate the county name[s] here.)	Free text

Assessment

Needs Assessment (PDO Only)

See DSP-MRT.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Capacity

Membership

See DSP-MRT.

Advisory Council and Other Workgroup Meetings

See DSP-MRT.

Grantee Funding Resources

See DSP-MRT.

Other Resources

Leveraged Resources

Use this section to enter information regarding leveraging resources, including grantee-level opioid workgroups and grantee-level funding resources. Grantee refers to the state, tribe/tribal organization, jurisdiction, local government entity, or other entity receiving the award from SAMHSA.

Unless the information changes from one reporting period to another, this information only needs to be entered once per fiscal year. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
Does a grantee-level workgroup exist in your state/tribal entity/jurisdiction addressing opioid issues (prescribing, misuse, treatment, overdose)?	Yes No
Does the opioid workgroup serve as your Advisory Council? (This item will only appear if “Yes” is selected for the previous item.)	Yes No
Does a grantee-wide strategic plan exist addressing opioid issues, including prevention of misuse, treatment, and overdose prevention?	Yes No
How are opioid prevention efforts integrated into the state-wide agenda for opioids?	Free text
In what ways have you coordinated opioid funding streams in your state/tribal entity/jurisdiction?	Free text
In what ways is your training curriculum informed by or congruent with the SAMHSA Opioid Overdose Prevention Toolkit?	Free text

Data Infrastructure

Use this section to enter information regarding data infrastructure and activities. Data infrastructure refers to a system or systems for collecting and disseminating data related to naloxone education trainings, distribution, and administration and opioid overdose. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
Do you have systems in place for collecting data on naloxone administrations?	Yes No
Which sectors report data into the system(s)? (This item will only appear if “Yes” is selected for the previous item.)	Corrections Courts Emergency Medical System (EMS) Emergency Medical Technician (EMT) Fire Departments Harm Reduction Agency Law Enforcement Other Social Service Organization Pharmacies Public Health Agencies Recovery Community Organization Shelters Substance Use Disorder Treatment Syringe Exchange Programs Other (specify)
During this reporting period, have you engaged in efforts to: … Enhance data infrastructure to track naloxone education trainings?	Yes No
… Enhance data infrastructure to track naloxone distribution or administration?	Yes No
… Enhance opioid overdose data infrastructure?	Yes No
… Enhance access to existing opioid overdose data sources?	Yes No
Did you provide naloxone or opioid-related data to local community stakeholders during this reporting period?	Yes No

Training and Technical Assistance (TA)

See DSP-MRT.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Planning

Accomplishments and Barriers/Challenges

See DSP-MRT.

Behavioral Health Disparities

Disparities Impact Statement

See DSP-MRT.

Population(s) Experiencing the Disparity

See DSP-MRT.

Focus and Data Gaps

See DSP-MRT.

Access to Prevention Efforts

See DSP-MRT.

Use and Reach of Prevention Efforts

See DSP-MRT.

Outcomes of Prevention Efforts

See DSP-MRT.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Implementation

Promising Approaches and Innovations

See DSP-MRT.

Policy

Use this section to report information about state-level policies related to naloxone or similar drugs. Most of the information will be prepopulated based on publicly available, state-level information at the time of the grant award. Please review for accuracy (to the best of your knowledge), and update this section when naloxone policies change in your state. Grantee refers to the state, tribe/tribal organization, jurisdiction, local government entity, or other entity receiving the award from SAMHSA. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Naloxone Access Laws

Item	Response Options
Does the state/tribal entity/jurisdiction have a naloxone access law (legislation designed to improve access to naloxone?) (If “Yes” is checked, the items below will appear.)	Yes No
Prescribing and Dispensing Policies
Do prescribers have CIVIL immunity for prescribing, dispensing, or distributing naloxone to a layperson?	Yes No
Do prescribers have CRIMINAL immunity for prescribing, dispensing, or distributing naloxone to a layperson?	Yes No
Do prescribers have DISCIPLINARY immunity for prescribing, dispensing, or distributing naloxone to a layperson?	Yes No
Do dispensers (pharmacists) have CIVIL immunity for prescribing, dispensing, or distributing naloxone to a layperson?	Yes No
Do dispensers (pharmacists) have CRIMINAL immunity for prescribing, dispensing, or distributing naloxone to a layperson?	Yes No

Item	Response Options
Do dispensers (pharmacists) have DISCIPLINARY immunity for prescribing, dispensing, or distributing naloxone to a layperson?	Yes No
Are prescriptions to third parties (e.g., family members, friends) authorized?	Yes No
Are insurers required to pay for naloxone drugs dispensed to third parties?	Yes No
Are insurers restricted from having a prior authorization policy for naloxone drugs prescriptions?	Yes No
Is prescription by a standing order authorized?	Yes No
Is a statewide standing order in place? (Will only appear if “Yes” is selected for the previous item.)	Yes No
Do pharmacists have authority to initiate prescriptions for naloxone (prescriptive authority)?	Yes No
Layperson Administration/Possession Policies
Is a layperson immune from CIVIL liability when administering naloxone drugs?	Yes No
Is a layperson immune from CRIMINAL liability when administering naloxone drugs?	Yes No
Is participation in a naloxone education program required as a condition of immunity?	Yes No

Good Samaritan Laws

Item	Response Options
Does the state have an overdose Good Samaritan law (legislation designed to reduce criminal concerns when a layperson summons aid during an overdose)? (If “Yes” is checked, the items below will appear.)	Yes No
What protection, if any, does the Good Samaritan law provide from controlled substance possession laws? Protection from … Arrest Charge Prosecution	Yes No (For each type of protection)
What protection, if any, does the Good Samaritan law provide from drug paraphernalia laws? Arrest Charge Prosecution	Yes No (For each type of protection)

Item	Response Option
Does the Good Samaritan law provide protection from parole or probation violations?	Yes No
Is reporting an overdose considered a mitigating factor in sentencing?	Yes No
Does the Good Samaritan law provide protection from outstanding warrants?	Yes No

High-Need Community Policies/Protocols

Use this section to provide information about whether local naloxone standing orders, collaborative practice agreements, or other policies exist within each of your selected high- need communities. “High-Need Community” is used to indicate the grantee’s selected high- need communities. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
Do any of your high-need communities have local naloxone standing orders, collaborative practice agreements, or other naloxone policies/protocols?	Yes No
High-Need Community (Will only appear if “Yes” is selected for the previous item.)	Community 1 Community 2 Etc.
Please provide a brief description of the local policies/protocols in this community. (Will only appear if “Yes” is selected for the first item in this section.)	Free text

Naloxone Education and Other Opioid-Related Trainings

High-Need Community-Level Trainings

Use this section to report information on the naloxone education and other opioid-related trainings offered in each selected high-need community during the reporting period. These trainings can include group or individual trainings. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
High-Need Community	Community 1 Community 2 Etc.
Number of requests for training services related to opioid and heroin overdose. (This should include training requests on how to administer naloxone or a drug or device approved or cleared under the Federal Food, Drug, and Cosmetic Act for emergency treatment of known or suspected opioid overdose.)	Numerical
Type of community-level training(s) provided. (Select all that apply.)	Naloxone Administration Other Opioid-Related Trainings (e.g., opioid prescribing, naloxone co- prescribing or dispensing, communicating with patients, medication-assisted treatment)

Item	Response Options
Naloxone Administration Trainings (If “Naloxone Administration” is checked for the previous item, the items in this section of the table will appear.)
Which of the following audience(s) received naloxone trainings as part of the grant during this reporting period? (Select all that apply.)	Professional first responders (e.g., law enforcement, emergency medical services, fire department) Lay person and community organization staff (e.g., family/friend/at-risk individuals, substance use disorder treatment staff) Other individuals (e.g., correctional staff) (specify)
If you selected professional first responders as one of your audiences, then the following questions will appear.
What is the approximate duration of the professional first responder training?	Numerical (minutes)
Number of professional first responder trainings provided during this reporting period	Numerical
Total number of professional first responders who participated in trainings during this reporting period	Numerical
Number of professional first responders who completed a post-survey	Numerical
Number of professional first responders completing post-surveys who reported feeling confident administering naloxone in case of an overdose	Numerical
Number of professional first responders completing post-surveys who reported perceiving they had learned new information or skills as a result of the training	Numerical
If layperson and community organization/agency staff is one of the selected audiences, then the following questions will appear.
What is the approximate duration of the layperson and community organization staff training?	Numerical (minutes)
Number of layperson and community staff trainings provided during this reporting period	Numerical
Total number of layperson and community staff who participated in trainings during this reporting period	Numerical
Number of layperson and community staff who completed a post-survey	Numerical

Item	Response Options
Naloxone Administration Trainings (If “Naloxone Administration” is checked for the previous item, the items in this section of the table will appear.)
Number of layperson and community staff completing post-surveys who reported feeling confident administering naloxone drugs in case of an overdose	Numerical
Number of layperson and community staff completing post-surveys who reported perceiving they had learned new information or skills as a result of the training	Numerical
If you selected other individuals as one of your audiences, then the following questions will appear.
Please specify the other individuals	Free text
What is the approximate duration of the trainings for other individuals?	Numerical (minutes)
Number of other individuals’ trainings provided during this reporting period	Numerical
Total number of other individuals who participated in trainings during this reporting period	Numerical
Number of other individuals who completed a post-survey	Numerical
Number of other individuals completing post- surveys who reported feeling confident administering naloxone drugs in case of an overdose	Numerical
Number of other individuals completing post- surveys who reported perceiving they had learned new information or skills as a result of the training	Numerical

Item	Response Options
Other Opioid-Related Trainings (If “Other Opioid-Related Trainings” is checked in the first item of this table, the items in this section of the table will appear.)
Audience of training(s)	Medical professionals (excluding pharmacists) Pharmacists Other (specify)
Please specify the other audience type. (If “Other” is selected in previous question.)	Free text
If “Medical professionals (excluding pharmacists)” is one of the selected audiences, then the following questions will appear.
Focus/Topic(s) of training(s) for “Medical professionals (excluding pharmacists).”	Free text
Number of trainings	Numerical
Total number of trainees	Numerical
If you selected “Pharmacists” as one of your audiences, then the following questions will appear.
Focus/Topic(s) of training(s) for pharmacists	Free text
Number of trainings	Numerical
Total number of trainees	Numerical
If “Other” is one of the selected audiences, then the following questions will appear.
Focus/Topic(s) of training(s) for other audiences.	Free text
Number of trainings	Numerical
Total number of trainees	Numerical

Grantee-Level Trainings

If you provided any grantee-level naloxone administration or other opioid-related trainings, use this section to report the grantee-level trainings you provided during the reporting period. Examples of grantee- level trainings include a training delivered to all pharmacists attending a state pharmacy conference or a naloxone administration training provided to all state police officers at a statewide training. Remember that trainings provided to enhance community partner capacity to implement the grant are reported under Implementation. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
Number of requests for training services related to opioid and heroin overdose. (This should include training requests on how to administer naloxone or a drug or device approved or cleared under the Federal Food, Drug, and Cosmetic Act for emergency treatment of known or suspected opioid overdose.)	Numerical
Did you provide any grantee-level naloxone administration or opioid-related trainings during this reporting period?	Yes No
Type of grantee-level training(s) provided. (Will only appear if “Yes” is selected for the previous item.) (If “Naloxone Administration” is checked, the items in the “Naloxone Administration Trainings” section of the previous table will appear. If “Other Opioid-Related Trainings” is checked, the items in the “Other Opioid-Related Trainings” section of the previous table will appear.)	Naloxone Administration Other Opioid-Related Trainings (e.g., opioid prescribing, naloxone co-prescribing or dispensing, communicating with patients, medication- assisted treatment)

Training Data Collection Information

Please provide information about the survey items you used to report trainee results.

Item	Response Options
Did your post-training surveys include a question related to respondents’ confidence?	Yes No
Please provide the exact wording, including response options, of the survey question(s) as well as any information that would be helpful in understanding the data (e.g., which response option[s] were included in the reported percentage). (If “Yes” is selected for the previous item.)	Free text
Did your post-training surveys include a question related to whether respondents learned new information and skills?	Yes No
Please provide the exact wording, including response options, of the survey question(s) as well as any information that would be helpful in understanding the data (e.g., which response option[s] were included in the reported percentage). (If “Yes” is selected for the previous item.)	Free text
Information about your training data collection/management tool and any additional information. (Please provide information about the data collection/management tool[s] you are using to track training data [such as a web-based data entry system] and any additional information that would be useful in understanding the training data you have provided.)	Free text

Naloxone Distribution Plan (PDO Only)

The Naloxone Distribution Plan section is a Work Plan report. From the Progress Report module, you can view a previously entered report after your Project Officer accepts it, however, you cannot add or edit a report. To add your Naloxone Plan for the first time, go to the Work Plans section on your Dashboard, go to the gear icon under Actions, and select the plus sign (+) option next to Naloxone Plan. To edit your Naloxone Plan, go to the Work Plans section on your Dashboard, go to the gear icon under Actions, and select the “Edit” option next to Naloxone Plan.

Upload and provide a brief description of your document. Use the Browse button to select a file from your computer, use the Upload button to add your document, enter a description, then click the Save button. If your document has not changed since your previous upload, then you do not need to upload a new document.

Naloxone Distribution

Costs

Use this section to report grant funds used to purchase naloxone during the reporting period. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
Total amount of grant funds spent on the purchase of naloxone products during this reporting period.	Currency

Item	Response Options
Type of kit purchased. Of the total grant funds spent to purchase kits, what amount was spent on and how many of each type of kit were purchased?
Nasal spray kits, 2 mg (Adapt/Narcan)	Funds Spent and Number of Kits
Nasal spray kits, 4 mg (Adapt/Narcan)	Funds Spent and Number of Kits
Injectable (intramuscular), .4 mg/10 ml vial kits (Hospira)	Funds Spent and Number of Kits
Injectable (intramuscular), .4 mg/1 ml vial kits (Mylan or West- Ward)	Funds Spent and Number of Kits
Injectable (intramuscular), 1 mg/2 ml vial kits (Aurum)	Funds Spent and Number of Kits
Auto-injector kits (Kaleo/Evzio)	Funds Spent and Number of Kits
Other Specify	Checkbox
Specify name of kit	Free text, Funds Spent, and Number of Kits
Other Specify	Checkbox
Specify name of kit	Free text, Funds Spent, and Number of Kits
Total amount spent on the purchase of naloxone products during this reporting period using funds from other sources (if known).	Funds Spent, Number of Kits, and Don’t Know checkbox
Comments	Free text

Kits Distributed to Partner Organizations

Use this section to report information regarding the distribution of naloxone kits to the selected high-need communities’ partner organizations. This includes distribution to partner organizations whose staff will be responsible for administering naloxone drugs (as in the case of law enforcement) and to partner organizations whose staff then distribute the naloxone drugs to family/friends/at-risk individuals (as may be the case with syringe exchange programs).

NEW MEASURE: How many kits do you plan to distribute through your grant?

You will first select the high-need community for which you are reporting; once you select a community, the partner organizations specific to that community (entered in the Administration > Partner Organizations section) will appear in a dropdown list, and you will report distribution to each relevant partner organization.

Item	Response Options
In the SPARS data collection system, the grantee must enter the data in this section for each partner organization reported in the “Administration” section by clicking on each community and partner organization above.
High-Need Community	Community 1 Community 2 Etc.
Partner Organization	Partner Org. 1 Partner Org. 2 Etc.
Total	Numerical
Type of kit distributed. Of the total distribution events, how many were:
Nasal spray kits, 2 mg (Adapt/Narcan)	Numerical
Nasal spray kits, 4 mg (Adapt/Narcan)	Numerical
Injectable (intramuscular), .4 mg/10 ml vial kits (Hospira)	Numerical
Injectable (intramuscular), .4 mg/1 ml vial kits (Mylan or West-Ward)	Numerical
Injectable (intramuscular), 1 mg/2 ml vial kits (Aurum)	Numerical
Auto-injector kits (Kaleo/Evzio)	Numerical
Other kits	Numerical
Other kits (specify name of kit)	Free text
Other kits	Numerical
Other kits (specify name of kit)	Free text

Item	Response Options
Total number of kits distributed to or procured by this organization using funds from other sources (if known)	Numerical and “Don’t Know” checkbox

Please provide information about the data collection/management tool(s) or system(s) you are using to track distribution and any additional information that would be useful in understanding the data you have provided.

Item	Response Options
Information about your distribution data collection/management tool and any additional information	Free text

Naloxone Administration by Partner Organization

Use this section to report information on the naloxone administrations reported during this reporting period by each of the partner organizations receiving naloxone or naloxone training from this grant. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Ideally, you will report all administration events reported by partner organizations, including those using kits paid for by this grant and those using kits paid for by other funding sources. However, if you are not able to report events using kits paid for by other sources, you will be able to report just those using kits paid for with grant funds.

You will first select the high-need community for which you are reporting; once you select a community, the partner organizations specific to that community (entered in the Administration > Partner Organizations section) will appear in a dropdown list, and you will report naloxone administration data provided to you by each relevant partner organization.

Item	Response Options
In the SPARS data collection system, the grantee must enter the data in this section for each high-need community and partner organization reported in the “Administration” section by clicking on each community and partner organization above.
High-Need Community	Community 1 Community 2 Etc.
Partner Organization	Partner Org. 1 Partner Org. 2 Etc.
Are you reporting all administration events reported by this organization or only events using a kit paid for by this grant?	All events Only those paid for by grant

Item	Response Options
Approximately what percentage of this organization’s kits were paid for using funds from this grant? (This item only appears if “All events” is selected.)	Percentage
Total number of administration events	Numerical
Type of kit administered. Of the total administration events, how many were:
Nasal spray kits, 2 mg (Adapt/Narcan)	Numerical
Nasal spray kits, 4 mg (Adapt/Narcan)	Numerical
Injectable (intramuscular), .4 mg/10 ml vial kits (Hospira)	Numerical
Injectable (intramuscular), .4 mg/1 ml vial kits (Mylan or West- Ward)	Numerical
Injectable (intramuscular), 1 mg/2 ml vial kits (Aurum)	Numerical
Auto-injector kits (Kaleo/Evzio)	Numerical
Other kits	Numerical
Other types of kits (specify name of kit)	Numerical
Other kits	Numerical
Other types of kits (specify name of kit)	Numerical
Single or Multiple Dose. Of the total administration events, how many consisted of:
A single dose/unit administered	Numerical
Multiple doses/units administered	Numerical
Unknown	Numerical
Location of administration. Of the total administration events, how many were administered …
At a private residence	Numerical
In a public outdoor location (e.g., street, park), car, camp, or shelter	Numerical
At an indoor public place/business (including hotel/motel)	Numerical
Unknown	Numerical
Other (Specify location)	Numerical
Other (Specify location)	Free text

Item	Response Options
Outcome of administration event. Of the total administration events, how many had the following outcome: Please record the acute outcome (at the scene, at time of event); there is not an expectation that grantee will monitor outcome after patient has been transported to the Emergency Department.
Overdose reversal		Numerical
Death		Numerical
Event was likely not an opioid overdose		Numerical
Unknown outcome		Numerical

Please provide information about the data collection/management tool(s) or system(s) you are using to track administration and any additional information that would be useful in understanding the data you have provided.

Item	Response Options
Information about your administration data collection/management tool and any additional information	Free text

Other Interventions

Use this section to report any other interventions you or your selected high-need communities implemented as part of this grant initiative during the reporting period. To respond at the grantee level, click the edit button to the right of the “Grantee” record below. To respond for each of your high-need communities, click the “Add Community Interventions” button. After your communities are added, you can use the edit button to modify the records, as needed. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs.”

Item	Response Options
High-Need Community	Community 1 Community 2 Etc.
Public Policy Interventions
Naloxone policy change effort	Checkbox
Pharmacy benefit strategy change (e.g., institute drug utilization reviews for high-dose opioids, add nasal naloxone to Medicaid formulary, remove prior authorization for naloxone)	Checkbox
Other policy intervention. If checked, a free text “specify” field will appear.	Checkbox
Community/Organizational Interventions
Collaboration with prescribers to obtain standing orders	Checkbox
Collaboration with pharmacies to distribute naloxone drugs	Checkbox
Solidifying partnerships with community entities experienced in naloxone distribution to laypeople	Checkbox
Solidifying partnerships with first responder agencies experienced in naloxone administration	Checkbox
Efforts to expand naloxone distribution to new community partners that have not received or distributed naloxone or related drugs previously	Checkbox
Enhancement of state or local cross-agency coordination of naloxone efforts	Checkbox
Other community/organizational intervention. If checked, a free text “specify” field will appear.	Checkbox
Information Dissemination for Prescribers/Pharmacists. (Information dissemination includes dissemination of print and electronic materials, speaking engagements targeting prescribers/pharmacists, etc. This does not include naloxone education, which is captured in the “Naloxone Education Trainings” section.)
Information dissemination to prescribers on naloxone co-prescribing and opioid overdose risk	Checkbox
Information dissemination to pharmacists on naloxone dispensing	Checkbox
Other effort related to information dissemination to prescribers/pharmacists. If checked, a free text “specify” field will appear.	Checkbox
Information Dissemination to Community Members
Media campaigns and community information dissemination about overdose, naloxone drugs, Good Samaritan laws	Checkbox
Messaging to pharmacy patients	Checkbox

Item	Response Options
Other effort related to information dissemination to community members. If checked, a free text “specify” field will appear.	Checkbox
Treatment and Recovery Access
Efforts or services to facilitate access to treatment and recovery	Checkbox
System changes for post-overdose or high-risk treatment/referral	Checkbox
Other effort related to treatment and recovery access. If checked, a free text “specify” field will appear.	Checkbox
Number of strategies developed to refer overdose victims and families to treatment services	Numerical
Number of overdose victims and families receiving information about treatment services	Numerical
Number of overdose victims receiving treatment	Numerical

Of those receiving treatment listed above, how many received:

Item	Response Options
Medication-Assisted Treatment (MAT)	Numerical
Counseling	Numerical
Behavioral Therapies	Numerical
Other	Numerical

Accomplishments and Barriers/Challenges

See DSP-MRT.

Evaluation

Evaluation Plan Upload

See DSP-MRT.

Evaluation Report

See DSP-MRT.

Other Document Upload

See DSP-MRT.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Sustainability

Accomplishments and Barriers/Challenges

See DSP-MRT.

Overdose Outcomes

Use this section to report annual numbers of opioid-related overdose and overdose deaths. The numbers should be aggregated across all types of opioids, whether opioid pain relievers or illicit opioids (e.g., heroin). You will report any data/time points that have become available prior to the report deadline.

Grantee is used to indicate the state or tribal area or jurisdiction receiving the award from SAMHSA. High-Need Community is used to indicate the grantee’s selected high-need communities.

Grantee-Level Overdose Data

First, report grantee-level adult (age 18+) data on emergency department and other hospital visits involving opioid overdose. In this section, Grantee-level refers to the state or tribal area or jurisdiction within which your grant program is funded. It does not refer to the aggregate of the selected high-need communities. State grantees do not need to report information in the “Population (Denominator)” and “Opioid Overdose Deaths” fields, as these data will be pulled from CDC’s WONDER database. Tribal and jurisdiction grantees are asked to provide data for these fields.

Grantees are asked to report both emergency department and hospitalization data, if available, but we are aware that some grantees may not have access to both types or either type of data. Grantees may also report opioid overdose events from a different data source, if desired, or if emergency department or hospitalizations data are not available.

Item	Response Options
2021	“Edit Overdose Data” link
2022	“Edit Overdose Data” link
2023, etc.	“Edit Overdose Data” link

Item	Population (Denominator)	Opioid Overdose Deaths	Emergency Department Visits Involving Opioid Overdose	Hospitalizations Involving Opioid Overdose	Other Opioid Overdose Events (optional)
Data Source and Comments: Please provide information about the data source, any additional information that would be useful in understanding the overdose data you have provided, or both.
Total	State grantees do not need to provide these data because they will be pulled from CDC WONDER. Tribal and jurisdiction grantees are asked to provide data for these fields.		Numerical	Numerical	Numerical
Data source			Free text	Free text	Free text
Additional Information			Free text	Free text	Free text
Age Note: Please complete the fields below, leaving fields blank if data are unknown.
15–24 yr	State grantees do not need to provide these data because they will be pulled from CDC WONDER. Tribal and jurisdiction grantees are asked to provide data for these fields.		Numerical	Numerical	Numerical
25–34 yr			Numerical	Numerical	Numerical
35–44 yr			Numerical	Numerical	Numerical
45–54 yr			Numerical	Numerical	Numerical
55–64 yr			Numerical	Numerical	Numerical
65+ yr			Numerical	Numerical	Numerical
Not Available			Numerical	Numerical	Numerical
Sex Note: The values entered for the age groups and the sexes must each total the values entered in the total line.
Males	State grantees do not need to provide these data because they will be pulled from CDC WONDER. Tribal and jurisdiction grantees are asked to provide data for these fields.		Numerical	Numerical	Numerical
Females			Numerical	Numerical	Numerical
Sex Not Available			Numerical	Numerical	Numerical

High-Need Community-Level Overdose Data

Next, you will report any community-level data that are available on opioid-related overdose deaths and events in your selected high-need communities.

Item	Response Options
2022 High-Need Community 1 High-Need Community 2 Etc.	“Edit Overdose Data” button
2023 High-Need Community 1 High-Need Community 2 Etc.	“Edit Overdose Data” button
2024, etc. High-Need Community 1 High-Need Community 2 Etc.	“Edit Overdose Data” button

			Emergency
			Department		Other
			Visits	Hospitalizations	Opioid
		Opioid	Involving	Involving	Overdose
	Population	Overdose	Opioid	Opioid	Events
Item	(Denominator)	Deaths	Overdose	Overdose	(optional)
Data Source and Comments Please provide information about the data source, any additional information that would be useful in understanding the overdose data you have provided, or both.
Total	Numerical	Numerical	Numerical	Numerical	Numerical
Data Source	Free text	Free text	Free text	Free text	Free text
Additional Information	Free text	Free text	Free text	Free text	Free text

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	DSP-MRT Supplement for FR-CARA and PDO Grants
Subject	Unique items supplement to the Division of State Programs–Management Reporting Tool (DSP–MRT) for First Responders-Comprehensive
Author	Substance Abuse and Mental Health Services Administration
File Modified	0000-00-00
File Created	2021-10-04