Form Harm Reduction Dat Harm Reduction Dat Harm Reduction Data Collection Form

Harm Reduction Grant Annual Data

(TARGET SETTING FORM COMPLETED ANNUALLY)

1. Organization Name: ____________________ 2. Grant Number: __________________

3. Project Year (circle one): 1 2 3 4

1. Service Encounter Target Setting (To be completed on an annual basis)

1. Total number of service encounters expected this year (In the field): ___ ___ ___ __

2. Total number of service encounters expected this year (At a facility): ___ ___ ___ __

2. Commodities Purchased Target Setting (To be completed on an annual basis)

1. Total number of safe sex kit supplies expected to be purchased: ___ ___ ___ __

2. Total number of naloxone kits expected to be purchased (1 kit=2 doses): ___ ___ ___ __

3. Total number of vending machines expected to be purchased/leased: ___ ___ ___ __

4. Total amount of stock for vending machines expected to be purchased: ___ ___ ___ __

5. Total number of medication lock boxes expected to be purchased: ___ ___ ___ __

6. Total number of sharps/medication disposal boxes expected to be purchased: ___ ___ ___ __

7. Total number of wound care management supplies expected to be purchased: ___ ___ ___ __

8. Total number of fentanyl test strips expected to be purchased: ___ ___ ___ __

9. Total number of other substance test strips expected to be purchased: ___ ___ ___ __

10. Total number of sterile syringes expected to be purchased: ___ ___ ___ __

11. Total number of safe smoking kits expected to be purchased: ___ ___ ___ __

3. Specific Harm Reduction Encounters Services Target Setting (To be completed on an annual basis)

Infectious Disease Prevention and Support Services

Overdose Prevention
Expected number of naloxone trainings to be provided: ___ __ ___ ___
Expected number of individuals to receive naloxone trainings: ___ __ ___ ___ Expected number of overdose education sessions to be provided: ___ __ ___ __ Expected number of individuals to receive overdose education trainings: ___ __ ___ __
Expected number of other overdose prevention services to be provided: ___ __ ___ __
Expected number of individuals to receive other overdose prevention services ___ __ ___ __

Mental and Physical Health Promotion

1. Expected number of counseling services to be provided: ___ __ ___ ___

2. Expected number health education sessions to be provided: ___ __ ___ ___

3. Expected number of other mental/physical/health promotion services to be provided: ___ __ __

Linkages to Treatment and Recovery Support Services

1. Expected number of linkages to peer services: ___ __ ___ ___

2. Expected number of linkages to treatment services: ___ __ ___ ___

3. Expected number of linkages to recovery services: ___ __ ___ ___

4. Expected number of other linkages to treatment and recovery support services: ___ __ ___ ___

DEMOGRAPHICS: Please enter the estimated number of encounters:

Gender (by encounters):

Female: ___ __ ___ ___

Male: ___ __ ___ ___

Transgender: ___ __ ___ ___

Non-Binary: ___ __ ___ ___

Other: ___ __ ___ ___

Race/Ethnicity (by encounters):

Ethnicity:

Hispanic, Latino/a, or Spanish Origin: ___ __ ___ ___

Not Hispanic, Latino/a, or Spanish Origin: ___ __ ___ ___

Race:

American Indian or Alaskan Native: ___ __ ___ ___

Asian: ___ __ ___ ___

Black or African American: ___ __ ___ ___

Native Hawaiian or Other Pacific Islander: ___ __ ___ ___

White: ___ __ ___ ___

Multiracial: ___ __ ___ ___

AGE (by encounters):
Under 14 years
15 to 17 years
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
65 years and older

Harm Reduction Grant Quarterly Data

PERFORMANCE REPORT

1. Organization Name: 2. Grant Number:

3. Project Year (circle one): 1 2 3 4 4. Quarter (Circle One): 1 2 3 4

PLEASE ENTER THE QUARTERLY TOTAL AMOUNT FOR EACH ITEM BELOW

Encounters Attained

Actual

Report Quarterly

Total Number of Service Encounters (Field)

 

Total Number of Service Encounters (Facility)

 

SERVICES

Infectious Disease Prevention and Support Services

Safe Sex Kit Supplies Purchased

 

Safe Sex Kit Supplies Distributed

 

HIV Testing

 

VH Testing

 

PREP Linkages

 

HIV Treatment Linkages

 

VH Treatment Linkages

 

VH Vaccination Services

 

Wound Care Management Supplies

 

Wound Care Management Services

Other Infectious Disease Prevention and Treatment

 

Overdose Prevention

Naloxone Kits Purchased (1 kit=2 doses)

 

Naloxone Kits Distributed (1 kit=2 doses)

 

Naloxone Trainings

 

Individuals Receiving Naloxone Training

 

Overdose Education Sessions

 

Individuals Receiving Overdose Education Sessions

 

Other Overdose Prevention Services

 

Individuals Receiving Other Overdose Prevention Services

 

Counseling Services

 

Health Education Sessions

 

Other Mental and Physical Health Promotion Services

 

Linkages to Treatment and Recovery Support Services

Linkages to Peer Services

 

Linkages to Treatment Services

 

Linkages to Recovery Services

 

Other Linkages to Treatment and Recovery Support Services

 

Safer Drug Use Services

Vending Machines Purchased or Leased

 

Stock for Vending Machines Purchased

 

Medication Lock Boxes Purchased

 

Medication Lock Boxes Distributed

 

Sharps/Medication Disposal Boxes Purchased

 

Sharps/Medication Disposal Boxes Distributed

 

Fentanyl Test Strips Purchased

 

Fentanyl Test Strips Distributed

 

Other Substance Test Strips Purchased

 

Other Substance Test Strips Distributed

 

Sterile Syringes Purchased

 

Sterile Syringes Distributed

 

Smoking Kits Purchased

 

Smoking Kits Distributed

 

Other Safer Drug Use Services

 

DEMOGRAPHICS

Gender (by encounters)

Female

 

Male

 

Transgender

 

Non-Binary

 

Other

 

Unknown/Not Provided

 

Race/Ethnicity (number of encounters)

Ethnicity (by encounters):

Hispanic, Latino/a, or Spanish Origin
Not Hispanic, Latino/a, or Spanish Origin

Race (by encounters):

American Indian or Alaskan Native

 

Asian

Black or African American

 

Native Hawaiian or Other Pacific Islander

 

White

 

Multiracial

 

Unknown/Not Provided

 

AGE (by encounters):
Under 14 years
15 to 17 years
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
65 years and older

QUARTERLY PROGRAM PROGRESS NARRATIVE:

Please use this section to describe the activities, challenges, successes, and innovations that have occurred during this reporting period.

Overall progress:

Challenges/Barriers:

Successes:

Innovations: