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

Harm Reduction Grant Program Target Setting and Quarterly Aggregate Reporting Instrument

Attachment A HR OMB Data Collection Form REVISED 05202022-clean

Harm Reduction Data Collection Form

OMB: 0930-0391

Document [docx]
Download: docx | pdf






Harm Reduction Grant Annual Data

(TARGET SETTING FORM COMPLETED ANNUALLY)

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

  1. 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): ___ ___ ___ __


  1. 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: ___ ___ ___ __



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


Infectious Disease Prevention and Support Services

Overdose Prevention


  1. Expected number of naloxone trainings to be provided: ___ __ ___ ___

  1. Expected number of individuals to receive naloxone trainings: ___ __ ___ ___

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

  3. Expected number of individuals to receive overdose education trainings: ___ __ ___ __

  1. Expected number of other overdose prevention services to be provided: ___ __ ___ __

  1. Expected number of individuals to receive other overdose prevention services ___ __ ___ __


Mental and Physical Health Promotion


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

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

  1. 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: ___ __ ___ ___


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


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


  1. 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:

  1. 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:








File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMulvey, Kevin P. (SAMHSA/CSAT)
File Modified0000-00-00
File Created2022-07-12

© 2024 OMB.report | Privacy Policy