ATTACHMENT 1
Annual Reporting Tool (ART) – Strategic Prevention Framework for Prescription Drugs (SPF Rx) |
Program Evaluation for Prevention (PEPC) – Cross-Site Evaluation |
OMB No. 0930-0377
Expiration Date December 31, 2025
Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of the Strategic Prevention Framework for Prescription Drugs (SPF Rx) grant program. This information collection will be used at an aggregate level to assess implementation of Strategic Prevention Framework steps, including related barriers and the reach of the SPF Rx interventions. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0377. Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Ln, Room 15 E57B, Rockville, MD 20857.
Timing of Instrument Items:
E = Every time (annually)
B = Baseline only
F = Final only
Section 1: Administrative Survey 5
Organization Type (Subrecipients only) 5
Funding History (Subrecipients only) 6
Section 2: Strategic Prevention Framework 7
Section 2A. Needs, Population of Focus, and Resources Assessments 7
Needs Assessment (Subrecipients only) 7
Data Sources (Subrecipients only) 7
Barriers (Subrecipients only) 10
Targeted Populations and Outcomes (Both grantees and subrecipients) 12
Section 2B. Capacity Building and Sustainability (Subrecipients only) 16
Current Capacity (Subrecipients only) 16
Training and Technical Assistance (Subrecipients only) 17
Development of SPF Rx Organizational Resources (Subrecipients only) 18
Relationship Building (Subrecipients only) 19
PDMP Data Access (Subrecipients only) 22
Barriers (Subrecipients only) 23
Sustainability (Subrecipients only) 24
Section 2C. Prevention Intervention Implementation (Both grantees and subrecipients complete) 26
Implemented Prevention Interventions 27
Prevention Intervention and Service Type Information 29
Community-Based Processes Sub-Form 33
Overall Population of Focus reached by this intervention-service type 35
Prevention Education Sub-Form 37
Overall Population of Focus served by this intervention-service type 38
Alternative Drug-Free Activities Sub-Form 40
Overall Population of Focus served by this intervention-service type 41
Problem Identification and Referral Sub-Form 44
Overall Population of Focus served by this intervention-service type 45
Environmental Strategies Sub-Form 47
I. Training and educating environmental influencers 47
II. Policy, regulation, or law enactment or implementation 49
III. Enforcement implementation 55
IV. Safe Storage and Disposal Strategies 55
V. Other Environmental Strategies 56
Overall Population of Focus reached by this intervention-service type 56
Information Dissemination Sub-Form 59
Overall Population of Focus reached by this intervention-service type 65
Section 2D. Monitoring and Evaluation (Subrecipients only) 69
Section 3: Broad Contextual Factors (Both grantees and subrecipients complete) 72
Section 4: Closing Questions (Both grantees and subrecipients complete) 74
The Annual Reporting Tool (ART) collects data annually from primary SPF Rx grantees and their subrecipient communities about SPF Rx implementation, including:
Subrecipient communities’ progress through the Strategic Prevention Framework (SPF); and
The specific prevention interventions being implemented by subrecipient communities and primary grantees.
For SPF Rx, interventions may be implemented by primary grantees as well as their community subrecipients. Subrecipient communities will complete the whole survey, while primary grantees will mainly report on prevention interventions that they implement. Data collected from the survey will be used to monitor subrecipient and state, tribal entity, or jurisdiction performance and evaluate the effectiveness of the Strategic Prevention Framework for Prescription Drugs (SPF Rx) program across states, tribal entities, and jurisdictions. The overall goal of the cross-site evaluation is to document and assess the effectiveness of the SPF Rx approach to SAMHSA’s mission of reducing prescription drug misuse.
Completion of this survey is a requirement of accepting funding from CSAP through your state, tribal entity, or jurisdiction under the SPF Rx grant initiative.
Make sure to read all of the directions and examples. Primary grantees and subrecipient communities will complete this form once for each Federal fiscal year (annually). To minimize respondent burden and decrease completion time, this web-based survey allows information entered in previous reporting periods to be prefilled where possible and uses skip patterns to take you automatically to the appropriate question on the basis of your responses.
You will need to complete separate forms related to implementation information for each set of prevention intervention activities implemented. For example, if your community/jurisdiction implements both a participant-based education prevention intervention and an environmental prevention intervention, you will complete implementation information for both of those interventions. Similarly, if your community implements two different participant-based prevention education intervention strategies, you will complete implementation information for both of those interventions.
Information provided in this instrument focuses on communities, so no individuals will be identified in the reporting of results.
Throughout this instrument, the term “you” refers to the primary SPF Rx grantee (state/tribal entity/jurisdiction) or the subrecipient community that has received SPF Rx funding from the state/tribal entity/jurisdiction. The SPF Rx subrecipient community could be an organization, coalition, or other entity.
You are strongly encouraged to obtain input from others involved with the SPF Rx-funded project at the grantee and/or subrecipient level. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, as appropriate and relevant for your SPF Rx grant.
People you may want to include in responding to this survey (if these positions are applicable to your grant)—
Project Director
Project Coordinator
Person with responsibility or knowledge of financial issues
State or Tribal Epidemiology and Outcomes Workgroup (SEOW) Liaison
Data Coordinator
Local Evaluator
Intervention delivery staff
Coalition representatives
Key stakeholders or partners
Before completing the survey, you may find it helpful to gather the following materials to help answer questions:
budgets;
results of needs and resources assessments;
strategic plans;
meeting minutes;
memoranda of understanding;
prevention intervention implementation materials (curricula, programs, etc.);
evaluation findings and reports; and
organizational policies.
As you enter your data, you will be able to save your work and come back to it at another time. We recommend that you write your responses to the open-ended questions requiring narrative information in advance using a word processor and copy and paste them into the web-based survey.
If you need assistance in using the web-based data entry system, contact the Help Desk by leaving a message at 866-245-8079 or by email at [email protected]. You can request assistance at any time and someone will respond to you within 24 hours or the next business day.
The following are definitions for several terms used throughout this instrument. Links to the definitions list can also be found on each page of the web-based survey.
Capacity refers to the quality and/or level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF Rx, capacity refers to the demonstrated ability of subrecipients to implement each SPF step effectively (e.g., implementation of evidence-based interventions) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model.
Capacity building refers to activities conducted to improve the ability of an organization or community to deliver prescription drug misuse prevention services, such as improving organizational resources; improving awareness about prescription drug misuse problems; building new relationships or strengthening existing relationships among coalitions, groups, and organizations involved in prescription drug misuse prevention; and working to ensure that prevention intervention activities and outcomes continue after funding ends.
Community refers to the politically or geographically defined area or culturally or epidemiologically defined population of focus that the subrecipient chooses for each prevention intervention.
Community needs and resources assessments examine needs and resources external to the organization and include community readiness (definition below), rates of prescription drug and opioid misuse, prevention resources (e.g., call centers, trained implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.
Community readiness is the community's level of awareness of, interest in, and ability and willingness to support prescription drug misuse prevention initiatives. More broadly, it connotes readiness for changes in community knowledge, attitudes, motives, policies, and actions.
Consequences are defined as the social, economic, and health problems associated with misuse of prescription drugs—for example, overdoses and deaths related to prescription drugs.
Consumption patterns are the ways in which people misuse prescription drugs.
Directly served refers to individual-based prevention strategies or services directly delivered to individuals, either on a one-on-one basis or in a group format. Typically, the service provider and the participant are at the same location during the service encounter, but these activities may also take place virtually. Examples include training sessions and educational classes.
Environmental strategies are efforts to establish or change community standards, codes, and attitudes and thus reduce the incidence and prevalence of prescription drug misuse. Approaches can center on legal and regulatory issues or can relate to service and action-oriented initiatives. Examples include technical assistance (TA) to communities to increase health care provider’s use of prescription drug monitoring program data when prescribing opioid pain medication.
Federal fiscal year goes from October 1 through September 30 of the following year.
Indirectly reached describes population-based prevention strategies aimed at impacting an entire population. Since there is no direct interaction between the populations impacted by the services, counts of people reached are typically estimates obtained from sources such as the Census or media outlets. Common indirect strategies include information dissemination and environmental strategies.
Intervening variables are risk or protective factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of prescription drug misuse and related risk behaviors and their consequences. These variables are the focus of prevention interventions, changes in which are then expected to affect consumption and consequences.
In-kind resources include labor that supports the SPF Rx grant at subsidized or no cost to the grant or other resources donated to the SPF Rx grant, such as equipment, supplies, or office space.
Interventions are funded activities carried out under the auspices of the SPF Rx grant. They target a variety of subpopulations with the objective of improving outcomes related to prescription drug and opioid misuse.
Key stakeholders are all the members of the community who have a vested interest (a stake) in the activities or outcomes of the SPF Rx prevention intervention.
Leveraging resources is the process of combining SPF Rx-funded resources with other resources to augment prevention intervention delivery (i.e., to do more together than with SPF Rx resources alone). For example, subrecipients combine SPF Rx funding with funding from another source [e.g., Comprehensive Addiction and Recovery Act (CARA) or CDC Overdose to Action grants) to augment the implementation of their SPF Rx intervention. In many instances, leveraging functions through collaborative relationships.
Participants are the recipients of the SPF Rx prevention interventions.
Primary grantee or grantee refers to the administrative entity (such as the state, tribal entity, or jurisdiction) receiving SPF Rx funds for delivery of prescription drug misuse prevention interventions.
Social marketing uses the principles of commercial marketing to develop, implement, and evaluate interventions designed to influence the behavior of a target audience.
Subrecipients are the entities (usually community-based organizations, schools, or coalitions) that receive funds from the grantee and carry out SPF Rx activities or prevention interventions.
Sustainability is the process through which a prevention system becomes a norm and is integrated into ongoing operations. Sustainability is vital to ensuring that prevention values and processes are firmly established, that partnerships are strengthened, and that financial and other resources are secured over the long term.
[GRANTEES SKIP TO QUESTION 8 AND COMPLETE TARGETED POPULATIONS AND OUTCOMES SUBSECTION]
This section asks questions that describe your subrecipient organization. Your subrecipient organization should be identified as the entity that is carrying out the activities/interventions of the SPF Rx program.
Subrecipient Name (System prefill) (locked)
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1. What type of organization would you say you are? You should identify your organization as the entity that will be carrying out the activities of the SPF Rx program. (Select the one response that best describes your organization.) B
Community coalition (If selected, you will skip Question 2.)
Local public health/mental health government agency responsible for substance use prevention
Local health/mental health care service provider or facility (e.g., local hospital, community mental health center)
Youth-focused local grassroots or community-based service or advocacy organization (e.g., local chapter of Students Against Destructive Decisions [SADD], local youth councils)
Non-youth-focused, local grassroots or community-based service or advocacy organization (e.g., substance use prevention organizations)
Faith-based organization
School or school district
Law enforcement organization
College or university
Tribal entity or organization
Other government agency, not listed above (Describe.) __________________________
Other nonprofit organization, not listed above (Describe.) _________________________
Other (Describe.)
2. Are you partnering with a community coalition (an existing group that brings together diverse organizations and individuals to collaborate on shared prevention goals) on your SPF Rx activities? By partnering, we mean that you have a formal relationship that is documented with a memorandum of understanding or similar agreement and/or that you provide SPF Rx funding to support activities of the coalition. (Select one response.) B, F
Yes
No
3. Has your subrecipient organization (i.e., entity that will be leading the activities of the SPF Rx) received Strategic Prevention Framework Partnerships for Success (SPF PFS) funding? (Select one response.)B
Yes (If selected, you will skip Question 4.)
No
Don’t know
4. Has your subrecipient organization (i.e., entity that will be leading the activities of the SPF Rx) been part of a coalition or group of organizations that received SPF PFS funding in the past? (Select one response.)B
This section asks for information related to the Strategic Prevention Framework steps. You will be asked to describe your activities related to the following steps:
Needs, population of focus, and resources assessments.
Capacity building and sustainability.
Prevention intervention implementation; and
Monitoring and evaluation.
[GRANTEES SKIP TO QUESTION 8, POPULATION OF FOCUS AND OUTCOMES]
This section collects information on organizational and community needs and resources assessments you conducted during this reporting period. First, you are asked whether the needs and resources of your community have been assessed. In this section, please also describe any data you have available and the data you used to conduct your needs and resources assessment. This section also asks about the consumption patterns, consequences, intervening variables, and populations you identified to target for your SPF Rx activities.
5. Has your organization completed an assessment of community needs and resources during the past Federal fiscal year? A community needs and resources assessment examines needs external to the organization and includes rates of substance use and related consequences (e.g., overdose), as well as community readiness, prevention resources (e.g., trained intervention implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.E
This set of questions asks about the availability of community-level prescription drug-related data for data-driven planning (e.g., needs assessments, identifying priority issues and intervening variables to target, performance monitoring). We want you to focus on local-level data that are available for your target community or communities.
6. For each of the types of data listed below, check the boxes to indicate (a) whether you have access to the data for your target communities (or closest available substate area), and (b) whether you used the data to conduct your community needs and resources assessment. Do NOT check “Yes” if the data are only available at the state level.E (autofill once completed initially)
Data Type |
Have access to community-level data |
The data were used for needs assessment |
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Yes |
No |
Yes |
No |
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Consumption |
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6.1. Prescription drug misuse in the past 30 days or past year |
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6.2. Prescription pain reliever misuse in the past 30 days or past year |
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6.3. Lifetime prescription drug misuse (ever misused) |
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6.4. Lifetime prescription pain reliever misuse (ever misused) |
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6.5. Other (Describe.) _____________________________ |
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Consequences |
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6.6. Mortality rates due to opioid overdose |
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6.7. Emergency department visits/hospital admissions related to opioid misuse/overdose |
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6.8. Calls to poison control center related to opioid misuse |
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6.9. Other (Describe.) _________________________ |
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Intervening Variables |
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6.10. Rate of registration of physicians with prescription drug monitoring program (PDMP) |
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6.11. Use of PDMP by physicians (number of queries; percentage of physicians making queries) |
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6.12. Rate of opioid prescribing |
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6.13. Rate of high-dose opioid prescribing (e.g., > 90MME/day or > 100MME/day) |
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6.14. Rate of opioid and benzodiazepine co-prescribing |
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6.15. Rate of multiple prescriber episodes for opioid pain medication (as indicator of possible “doctor shopping”) |
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6.16. Rate of multiple pharmacy episodes for opioid pain medication |
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6.17. Other PDMP measure of opioid prescribing (Describe.) _______________________________ |
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6.18. Consumers’ perceived risk of prescription drug misuse |
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6.19. Parent/peer attitudes about prescription drug misuse |
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6.20. Communication with parents about drug use |
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6.21. Social availability (e.g., through friends or family members) |
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6.22. Physicians’ attitudes and knowledge |
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6.23. Law enforcement practices (e.g., to address diversion; having police use Narcan to prevent overdose) |
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6.24. Other (Describe.) _____________________________ |
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In this section, we would like to learn about challenges that had an impact on assessing the needs, population of focus, and resources in your community, state, tribal area, or jurisdiction during this reporting period.
7. How much did the following factors impact the progress or results of your SPF Rx efforts related to conducting an assessment of community needs and resources in the past Federal fiscal year?
Note: If a specific item is not yet applicable or you do not know the answer based on your stage of implementation, you should check “No impact.”
Factors Impacting Needs Assessment E |
No impact |
Low impact |
Moderate impact |
High impact |
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This set of questions asks about the specific populations and outcomes your community, state, tribal entity, or jurisdiction has identified for your SPF Rx efforts. (Note: Grantees should report their overall targets for their state, jurisdiction, or tribal area) Complete at baseline and update annually if you have any changes.
8. Indicate the consumption pattern(s) you are targeting for your SPF Rx activities. (Select all that apply.)E (autofill once completed initially)
Have not identified a consumption pattern to target
Misuse of any prescription drugs
Misuse of prescription pain relievers
Misuse of prescription stimulants
Other consumption pattern (Describe.)
9. Indicate the consequence(s) you are targeting for your SPF Rx activities. (Select all that apply.)E (autofill once completed initially)
Have not identified a consequence to target
Emergency department visits or hospitalizations related to prescription drug overdose
Emergency department visits or hospitalizations related to opioid overdose
Poison control center calls related to prescription drug overdose
Poison control center calls related to opioid overdose
Prescription drug-related overdose deaths
Opioid-related overdose deaths
Motor vehicle crashes related to prescription drug or opioid misuse
Other consequences (Describe.)
10. Indicate the population(s) you will be focusing on for your SPF Rx prevention activities. In the first column, we would like to know if you have very specific groups of people you are focusing on for your prevention interventions. For example, if you are delivering a prevention intervention to all middle schools in an area, then you would select only “middle school students”; you would not have to select all the possible race/ethnicity categories that might be enrolled in the schools. If, however, you are delivering a prevention intervention specifically designed to target high school-aged Latinos, then you would select Hispanic and high school students. (Note: If you are targeting the whole community or jurisdiction, then choose that answer option [9.1], and do not check all the subpopulations.) (These categories are not mutually exclusive. Use your judgment to select all responses that describe your population of focus.)E (autofill once completed initially)
In the second column, check any specific subpopulation your SPF Rx prevention activities are focused on to reduce prescription drug misuse-related behavioral health disparities. According to Healthy People 2030, “Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” We are asking you to specify which of the population(s) you are targeting for your SPR Rx activities because they experience disparities within your target community or communities.
Population |
Check if you are specifically focusing on this subpopulation |
Check if this subpopulation represents your behavioral health disparities population of focus |
10.1. We are targeting community-wide or statewide population, not any specific subpopulations |
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N/A |
10.2. Males |
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10.3. Females |
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10.4. LGBTQ |
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10.5. African Americans |
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10.6. American Indians |
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10.7. Alaska Natives |
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10.8. Asian/Pacific Islanders |
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10.9. Hispanics |
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10.10. Whites |
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10.11. Ages 12–17 |
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10.12. Ages 18–25 |
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10.13. Ages 26 and over |
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10.14. Other age group (Specify.) ___________________ |
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10.15. Middle school students |
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10.16. High school students |
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10.17. College students |
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10.18. Parents |
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N/A |
10.19. Current or former military or military families |
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10.20. Individuals living in poverty |
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10.21. Individuals whose native language is other than English |
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10.22. Individuals with low literacy |
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10.23. Individuals with mental illness |
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10.24. Individuals with disabilities (e.g., hearing, visually, or physically impaired) |
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10.25. Physicians/health care providers/prescribers |
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N/A |
10.26. Pharmacists/dispensers |
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N/A |
10.27. Other population of focus (Specify.) _______________________________________ |
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10.28. Other population of focus (Specify.) _______________________________________ |
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10.29. Other population of focus (Specify.) _______________________________________ |
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11. Indicate the intervening variable(s) you will be targeting for SPF Rx prevention. (Select all that apply.)E (autofill once completed initially)
Have not yet selected an intervening variable to target
Laws or regulations related to prescription drug monitoring program (PDMP) data (access, use, timeliness, or quality)
Laws or policies related to prescriber or dispenser training or practices
Other laws or policies related to prescription drugs/pain medications
Law enforcement practices (e.g., to address diversion, having police use Narcan to treat suspected overdose)
Social access to prescription drugs (e.g., through friends or family members)
Physician attitudes and knowledge about safe prescribing practices
Physician/prescriber registration with prescription drug monitoring program
Physician/prescriber use of prescription drug monitoring program (number of queries; percentage of physicians making queries)
Rate of opioid prescribing
Rate of high-dose (> 90 MME/day) opioid prescribing
Rate of opioid and benzodiazepine co-prescribing
Rate of multiple prescriber episodes for opioid pain medications (or other indicators of possible “doctor shopping”)
Rate of multiple pharmacy episodes for opioid pain medication
Norms—perceived parent or peer attitudes or both (towards prescription drug misuse)
Norms—perceived peer or friend misuse of prescription drugs
Consumers’ perceived risk of harm of prescription drug misuse
Consumers’ perceived risk of getting caught misusing prescription drugs
Family communication around prescription drug misuse
Resistance or life skills or both
Other intervening variable (Describe.)
Other intervening variable (Describe.)
Other intervening variable (Describe.)
12. How would you describe the community or communities that you are targeting for your SPF Rx prescription drug misuse prevention activities? (Select all that apply.)E (autofill once completed initially)
Entire state/jurisdiction
Large urban area(s) (population of more than 500,000)
Smaller urban area(s) (population of 50,001 to 500,000)
Small town or urban cluster(s) (population of 2,500 to 50,000)
Rural area(s)
Other (Describe.)
[GRANTEES SKIP TO SECTION 2C PREVENTION INTERVENTION IMPLEMENTATION]
In this section, we ask you about your activities related to capacity and sustainability. Capacity refers to the quality and level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF Rx, capacity refers to the demonstrated ability of subrecipients to effectively implement each SPF step (i.e., assess needs, build capacity, plan, implement, and evaluate) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model. Capacity building refers to activities conducted to improve the ability of an organization or community to deliver prescription drug misuse prevention services, such as improving organizational resources, seeking and receiving relevant training and technical assistance (T/TA), building new relationships or strengthening existing relationships among groups and organizations involved in prescription drug misuse prevention, and ensuring that prevention intervention activities and outcomes continue after SPF Rx funding ends.
13. How much would you agree or disagree that your organization currently has enough capacity in each of the following areas to effectively implement your SPF Rx prevention efforts? (Note: At baseline, the questions should be answered with regard to your organization’s capacity at the time you received SPF Rx funds.) E
Capacity areas |
Strongly disagree |
Disagree |
Agree |
Strongly agree |
13.1. Capability and experience using the 5 SPF steps |
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13.2. Experience with the populations of focus for prescription drug misuse prevention |
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13.3. Experience working with health care providers and pharmacists for prescription drug misuse prevention |
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13.4. Experience with relevant interventions for prevention of prescription drug misuse |
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13.5. Experience collaborating with other organizations on interventions to prevent prescription drug misuse |
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13.6. Capability to use prescription drug monitoring program (PDMP) data for prevention planning, surveillance, and evaluation |
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13.7. Staff with the right skills to effectively implement SPF Rx prevention efforts |
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13.8. Enough staff to effectively implement SPF Rx prevention efforts |
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13.9. Enough fiscal/financial resources to effectively implement SPF Rx prevention efforts |
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13.10. Capability to sustain the prevention efforts over time |
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13.11. Experience addressing behavioral health disparities in prevention efforts |
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14. Select the area(s) in which your organization or staff needed and/or received SPF Rx-related guidance or training and technical assistance (T/TA) during the past Federal fiscal year. We are specifically asking about guidance and T/TA that contributed to your SPF Rx activities. (Select all that apply.) E
We did not need or receive any guidance or T/TA that contributed to SPF Rx activities
Training/technical assistance (T/TA) areas |
Needed or need T/TA in this area during the past Federal fiscal year |
Received T/TA in this area during the past Federal fiscal year |
14.1. Assessing community needs and resources |
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14.2. Using prescription drug monitoring program (PDMP) data for prevention surveillance, planning, or evaluation |
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14.3. Using other data sources for prevention assessment, planning, and evaluation |
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14.4. Understanding opioid misuse and epidemiology, including risk and protective factors |
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14.5. Developing a strategic plan for substance use prevention |
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14.6. Building collaborative relationships with stakeholders and partner agencies |
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14.7. Working with medical and pharmaceutical communities to prevent prescription drug misuse |
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14.8. Developing strategies to enhance PDMP use |
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14.9. Identifying and selecting prescription drug misuse interventions |
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14.10. Recruiting intervention participants |
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14.11. Adapting interventions for prescription drug misuse |
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14.12. Delivering culturally competent interventions |
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14.13. Addressing behavioral health disparities |
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14.14. Evaluating interventions for prescription drug misuse |
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14.15. Sustaining interventions for prescription drug misuse |
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14.16. Conducting social marketing/social media/public education |
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14.17. Leveraging strategies to increase safe storage and disposal of prescription drugs |
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14.18. Working with law enforcement to prevent prescription drug misuse |
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14.19. Engaging in public policymaking (e.g., collaborating to inform or implement policy change) |
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14.20. Other (Describe.) __________________________________ |
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14.21. Other (Describe.) __________________________________ |
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14.22. Other (Describe.) __________________________________ |
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This section collects information on the activities you conducted to improve your SPF Rx organizational capacity and which funding resources you had available for SPF Rx activities.
15. Other than training and obtaining technical assistance (TA), have you conducted activities that produced gains in your SPF Rx organizational resources or capabilities related to SPF Rx during the past Federal fiscal year? These could include such activities as recruiting community partners and improving staff and funding. (Select one response.)E
Yes
No (If selected, you will skip Question 16.)
16. Besides training and obtaining TA, indicate the activity or activities you conducted during the past Federal fiscal year that produced gains in your SPF Rx organizational resources. (Select all that apply.)E
Created an advisory board
Recruited new community partners
Increased staffing
Secured additional funding
Secured physical space
Modified or developed data infrastructure (for prescription drug prevention efforts)
Other: (Describe.)
17. Below is a list of funding sources that could be used to support prevention of prescription drug misuse. Please indicate whether your organization has used funding from this source to support SPF Rx–related activities during the past Federal fiscal year. Consult with your SPF Rx grantee if you are unsure of some of these funding sources. Do not include funding received by other organizations in your coalition or group, unless those funds are used for SPF Rx–related activities.E
Source of funding/resources |
Used funding from this source to support SPF Rx–related activities during the past Federal Fiscal year? |
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YES |
NO |
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17.1. SAMHSA Strategic Prevention Framework Partnerships for Success (SPF PFS) |
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17.2. SAMHSA Substance Abuse Prevention and Treatment Block Grant |
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17.3. SAMHSA Grants to Prevent Prescription Drug/Opioid Overdose-Related Deaths (PDO) |
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17.4. SAMHSA Medication-Assisted Treatment-Prescription Drug and Opioid Addiction (MAT-PDOA) |
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17.5. SAMHSA State Targeted Response to the Opioid Crisis Grants (Opioid STR) |
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17.6. SAMHSA Comprehensive Addiction and Recovery Act (CARA) Local Drug Crises Grants |
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17.7. SAMHSA First Responders-Comprehensive Addiction and Recovery Act (FR-CARA) |
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17.8. SAMHSA Harm Reduction Program Grant |
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17.9. SAMHSA HIV Capacity Building Initiative (HIV CBI) |
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17.10. SAMHSA Substance Abuse and HIV Prevention Navigator Program for Racial/Ethnic Minorities |
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17.11. SAMHSA Sober Truth on Preventing (STOP) Underage Drinking |
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17.12. CDC Overdose Data to Action (OD2A) |
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17.13. Bureau of Justice Assistance (BJA) Harold Rogers Prescription Drug Monitoring Program (PDMP) |
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17.14. HRSA Rural Opioid Overdose Reversal (ROOR) |
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17.15. Drug-Free Communities (DFC) grant |
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17.16. Medicaid (Federal, state, local) |
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17.17. Other Federal funds (Describe.) _______________________________________ |
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17.18. Other state/tribal/jurisdiction funds (Describe.) _______________________________________ |
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17.19. Other local government funds (Describe.) _______________________________________ |
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17.20. Foundations/nonprofit organizations |
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17.21. Corporate/business entities |
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17.22. Individual donations/funding from fundraising events |
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17.23. Other (Describe.) _______________________________________ |
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This section collects information on partners you identified to join in planning or delivering your SPF Rx prevention intervention activities.
18. Have you identified key stakeholders, partners, or partner organizations to participate in your SPF Rx planning and prevention intervention activities? This includes coalition members if you are working with a coalition. (Select one response.)E
Yes
No (If selected, you will skip Question 19.)
19. Provide more information on the key stakeholders, partners, and partner organizations that participate in your organization’s SPF Rx activities. This may include a combination of individuals and organizations. “Active” refers to stakeholders/partners who demonstrated support or participation in your activities and interventions during the past Federal fiscal year.E (autofill column 2 after initially completed)
We did not have any key stakeholders, partners, or partner organizations participate in our SPF Rx related activities during the past Federal fiscal year
Sector |
For each sector below, how many of these key stakeholder or partner members were “active” during the past Federal Fiscal year? |
What was the average level of involvement for the members of this sector in your SPF Rx activities during the past Federal Fiscal year? (Mark only if # active partners >0) |
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Low |
Medium |
High |
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19.1. Physicians/health care providers or health care organizations (excluding hospitals/hospital staff) |
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19.2. Hospital medical staff or hospital organization |
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19.3. Dentists or dental organizations |
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19.4. Pharmacists/pharmacy organizations |
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19.5. Substance use prevention professionals/organizations |
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19.6. Substance use treatment professionals/organizations |
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19.7. Mental health professionals/agencies |
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19.8. Insurance professionals or organizations |
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19.9. Youth groups/representatives |
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19.10. Schools/school districts |
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19.11. Colleges and universities |
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19.12. Other youth-serving professionals/organizations |
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19.13. Parents/family/caregiver groups |
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19.14. Tribal leaders or elders |
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19.15. Business community |
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19.16. Workers’ compensation programs |
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19.17. Media (radio/TV stations; newspapers) |
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19.18. Clergy/faith-based organizations |
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19.19. Civic or volunteer organizations/professionals |
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19.20. Organizations/individuals serving LGBTQ population |
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19.21. Military professionals/agencies |
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19.22. Law enforcement professionals/agencies |
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19.23. Courts/judiciary system professionals/agencies |
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19.24. Other state, local, or tribal government agencies (Describe.) _____________ |
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19.25. Other organizations/sectors (Describe.) _____________ |
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19.26. Other organizations/sectors (Describe.) _____________ |
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19.27. Other organizations/sectors (Describe.) _____________ |
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20. Did your community have access to community-level prescription drug monitoring program (PDMP) data/reports for prevention planning prior to the SPF Rx 2021 grant?B
Yes, we had access to community-level PDMP data but did not normally use it for prevention planning.
Yes, we had access to and normally used community-level PDMP data for prevention planning.
No, we did not have access to community-level PDMP data.
21. During the past Federal fiscal year, approximately how often did you receive or access updated PDMP data/reports for your SPF Rx target communities (or the closest available substate area)? (Select one)E
We did not receive or access any PDMP data/reports in the past fiscal year
Once
Semi-annually (twice per year)
Quarterly
Every other month
Monthly
Other (Specify.)
22. For what geographic area are PDMP data/reports available to you? (Select all that apply.)E (update annually only if it changes)
PDMP data are not available to us yet
Community
County
District or Region
State
Other (Specify.) _________________________________________________________
23. Are privacy or HIPAA concerns a major barrier to receiving community-level PDMP reports?E (update annually only if it changes)
Yes
No
24. How has your access to and use of community-level PDMP data/reports as part of your SPF Rx effort affected your local prevention efforts? (Select all that apply.) F
We did not get access to any community-level PDMP data/reports during the grant
We had access to community-level PDMP data/reports, but we were not able to use them
PDMP data did not significantly change our prevention approach
PDMP data changed our understanding of the problem
PDMP data guided local prevention strategies in new directions
PDMP data enabled us to better monitor risky prescribing and dispensing patterns
PDMP data informed enforcement efforts in new ways
Other (Describe.)
In this section, we would like to learn about challenges that had an impact on building capacity in your community, state, tribal area, or jurisdiction during this reporting period.
25. How much did the following factors impact the progress or results of your SPF Rx efforts related to improving the ability of your organization or community to deliver prescription drug misuse prevention services in the past Federal fiscal year? E
Note: If a specific item is not yet applicable or you do not know the answer based on your stage of implementation, you should check the box “No impact.”
Factors Impacting Capacity Building |
No impact |
Low impact |
Moderate impact |
High impact |
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This section asks about things you have done to ensure that SPF Rx–related prevention intervention activities and outcomes continue once SPF Rx funding ends. These efforts might focus on ensuring continued funding, structures, networks, partnerships, leadership, and resources.
26. During the past Federal fiscal year, how have you worked to ensure that prescription drug misuse prevention intervention activities and outcomes continue after SPF Rx funding has ended? (Select all that apply.)E
Have not done work in the past year to ensure that prescription drug misuse prevention intervention activities and outcomes continue after SPF Rx funding has ended
Leveraged, redirected, or realigned other funding sources or in-kind resources to carry on SPF Rx efforts
Obtained new funding (e.g., used the success of the SPF Rx efforts to secure other funds)
Worked to ensure that prescription drug misuse prevention intervention activities are incorporated into the missions/goals and activities of other organizations (e.g., medical boards, local pharmacies, school districts, law enforcement agency)
Worked to ensure that prescription drug misuse prevention staff positions are integrated into other organizations (e.g., health departments, school districts, community agencies)
Worked to gain formal adoption of prescription drug misuse prevention intervention activities into other organizations’ practices (e.g., health care provider organizations, pharmacies, medical school curriculum, school district curriculum, organizational policy change)
Worked to inform, help implement, or provide education related to new laws, policies, or regulations to guarantee the continuation of prescription drug misuse prevention intervention activities or outcomes
Worked on developing a prescription drug misuse partnership structure that will continue to function beyond the end of the SPF Rx grant period
Worked to create sustainable data infrastructure and staffing to continue to monitor PDMP and other surveillance data after SPF Rx grant ends
Other (Describe.)
This section collects information about the SPF Rx prevention interventions you selected for implementation in your service area. A prevention intervention is an activity or set of activities to which a group or community is exposed to in order to change their behavior. For SPF Rx, these activities should aim to prevent or lower the rate of prescription drug misuse and related problems. Interventions include activities related to:
Community-based processes (e.g., holding meetings or training with community members, reallocating funds to prevention activities in the community, reorganizing local agencies and organizations to address prevention of prescription drug misuse)
Prevention education (e.g., mentoring, school-based youth education programs, parenting programs)
Alternative activities (e.g., free social and recreational events, events at community drop-in centers or youth centers),
Problem identification and referral (e.g., student screening and referral)
Environmental strategies (e.g., training of environmental influencers, policy change, enforcement)
Information dissemination and other communication activities (e.g., conducting media campaigns, distribution of materials at health fairs)
Refer to the Annual Reporting Tool (ART) manual for more information on prevention interventions.
27. Did you or your community partners deliver any SPF Rx–related prevention interventions during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Questions 28–147.)
28. Name all the prevention interventions you or your partners delivered during this reporting period as part of your SPF Rx efforts. Refer to the Annual Reporting Tool (ART) Manual before you complete this section. That document will help you understand what to report as a prevention intervention; which activities you should list as separate service types related to that intervention; and how to determine the appropriate CSAP strategy type, Institute of Medicine category, and so on.E (autofill for interventions previously reported, except for active/inactive status)
You will need to complete a separate implementation information sub-form for each prevention intervention-service type you name below that was active during the past Federal fiscal year. The CSAP strategy type will determine a subset of questions you must complete for the prevention intervention and service type.
28a. Intervention name |
28b. Service type |
28c. Service type name |
28d. Date started |
28e. CSAP strategy type |
28f. Institute of Medicine (IOM) category |
28g. Status |
28h. Date completed or discontinued |
From the drop-down menu, select the name of each prevention intervention you are implementing, or select “other” and write in the name. To review a full list of the intervention names, refer to the Intervention Name List. |
From the drop-down menu, select the service type for each major set of services or activities you are implementing under this prevention intervention, or select “other” and write in the name. Many strategies may consist of only one service type. |
Write in the name of the specific set of services or activities that you implemented as part of your intervention if this name differs from the service type label. |
Date you began funding this intervention-service type through your SPF Rx initiative (MM/YYYY) |
Select the CSAP strategy type that best describes this intervention-service type:
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Select the IOM category for this intervention-service type:
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Check whether the intervention-service type was Active, Inactive, Completed, or Discontinued during the past Federal fiscal year. |
For intervention-service types completed or discontinued during the past year, indicate the date completed or discontinued (MM/YYYY). |
Sample Table:
28a. Intervention name |
28b. Service type |
28c. Service type name |
28d. Date started |
28e. CSAP strategy type |
28f. Institute of Medicine (IOM) category |
28g. Status |
28h. Date completed or discontinued |
Train/educate health care providers on safe prescribing/CDC guidelines |
Training/ educating environmental influencers |
Training/ educating environmental influencers |
03/2022 |
Environmental |
Universal indirect |
Completed |
09/2023 |
Media campaign—Count it! Lock it! Drop it! |
Media campaigns |
Media campaigns |
05/2022 |
Information dissemination |
Universal direct |
Active |
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Policy, reg, or law change/ implementation—prescriber opioid training |
Change/ implement new public policies, regs, or laws |
Change/ implement new public policies, regs, or laws |
10/2022 |
Environmental |
Universal indirect |
Completed
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12/2023 |
Prescription Drug Safe Storage and/or Disposal—Drop Box Installation |
Prescription drug safe storage and/or disposal
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Prescription drug safe storage and/or disposal |
01/2022 |
Environmental |
Universal indirect |
Completed |
01/2023 |
Questions in this section are only asked for each intervention active, inactive, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________E (autofill from Question 26)
29. What specific consumption pattern(s) or consequence(s) (or both) are the prevention intervention intended to target? (Select all that apply.)E (autofill after first completed)
Misuse of any prescription drugs
Misuse of prescription pain relievers
Misuse of prescription stimulants
Misuse of prescription benzodiazepines
Prescription drug/opioid-related deaths
Emergency department visits or hospitalizations related to prescription drug/opioid overdose
Poisoning center calls related to prescription drug/opioid overdoses
Motor vehicle crashes related to prescription drug or opioid misuse
Crime related to prescription drug or opioid misuse
Other consumption pattern (Describe.)
Other consequence (Describe.)
30. What specific intervening variable(s) is the prevention intervention intended to target? (Select all that apply.)E (autofill after first completed)
This intervention is not targeting a specific intervening variable
Laws or regulations related to prescription drug monitoring program (PDMP) data (access, use, timeliness, or quality)
Laws or policies related to prescriber or dispenser training or practices
Other laws or policies related to prescription drugs/pain medications
Law enforcement practices (e.g., to address diversion, having police use Narcan to treat suspected overdose)
Social access to prescription drugs (e.g., through family and friends)
Physicians’ attitudes and knowledge about safe prescribing practices
Physician/prescriber registration with PDMP
Physician/prescriber use of PDMP (number of queries; percentage of physicians making queries)
Rate of opioid prescribing
Rates of high-dose opioid prescribing (> 90MME/day)
Rate of opioid and benzodiazepine co-prescribing
Rates of multiple prescriber episodes for opioid pain relievers (as indicator of possible “doctor shopping”)
Rates of multiple pharmacy episodes for opioid pain medication
Norms—perceived parent or peer attitudes or both (towards prescription drug misuse)
Norms—perceived friend or peer misuse of prescription drugs
Consumers’ perceived risk of harm of prescription drug misuse
Consumers’ perceived risk of getting caught misusing prescription drugs
Family communication around prescription drug misuse
Resistance or life skills or both
Availability of prosocial activities
Other intervening variable (Describe.)
Other intervening variable (Describe.)
Other intervening variable (Describe.)
31. To your knowledge, is this intervention an evidence-based program, policy, or practice (EBPPP)? EBPPPs are defined as interventions that come from a Federal Registry, were reported as effective for your target substance in a published scientific journal article, were based on a documented theory of change, or were deemed effective by a panel of experts (Select one response.)E (autofill after first completed)
Yes
No
Don’t know
32. How did you select your intervention? (Select all that apply.)E (autofill after first completed)
Inclusion in a Federal registry of evidence-based interventions
Found to be effective (on the primary targeted outcome) in a published, scientific journal
Similar in content and structure to interventions that appear in registries or peer-reviewed literature
Supported by documentation of effective implementation multiple times in the past (showing consistent pattern of positive effects)
Reviewed by a panel of informed experts including qualified prevention researchers, local prevention practitioners, and key community leaders (e.g., law enforcement and education representatives, elders within indigenous cultures)
Recommended by evidence-based practice workgroup (EBPW)
Appeared on a list of recommended promising or evidence-based programs, policies, and practices provided by our state, tribal entity, or jurisdiction
Recommended by the SPF Rx grantee (state, tribe, or jurisdiction) but not on a formal list of promising or evidence-based programs, policies, and practices
Is based on guidelines, protocols, standards, or preferred practice patterns that have been proven to lead to effective prevention outcomes
Based on a theory of change that is documented in a clear logic or conceptual model
Other (Describe.)
33. Have you renamed the existing promising or evidence-based program, policy, or practice to implement it in your community? (Select one response.) E (autofill after first completed)
Yes (Provide the original name.)
No
34. Which of the following best describes the implementation history of this prevention intervention in your community? (Select one response.)E (autofill after first completed)
Not implemented in the community before SPF Rx 2021 funding
Continuation of a PFS or SPF Rx 2016 prevention intervention
Continuation of a non-PFS or non-SPF Rx 2016 prevention intervention
35. Were any adaptations made to address the cultural appropriateness of the prevention intervention for a particular group (e.g., modifying the language or slang used, modifying the examples, including visuals of individuals who represent your population of focus) in the past Federal fiscal year? (Select one response.)E
Yes (Describe the adaptations.)
No
36. Did you collaborate with any organizations or individuals to implement this intervention for SPF Rx in the past Federal fiscal year? E
Yes
No
Don’t know
Service type questions
Questions in this section are only asked for each intervention active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________ (autofill from Question 28)
Service Type: ___________________________________________ (autofill from Question 28)
37. For Questions 37.1–37.5, indicate the locations and population of focus being served by this prevention intervention-service type. If you are implementing in separate settings (e.g., schools, workplaces), list each setting separately. (Note: If you are implementing a media campaign that reaches the whole county, you may enter “countywide” for location [Question 37.1].)
Use one line to describe each location served by the intervention-service type. Other than estimated population of focus (Question 37.5), you need to complete only those categories that are appropriate for this prevention intervention-service type and community served.E (autofill after first completed)
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37.1. Location (e.g., school name, business, community center) |
37.2. City/town |
37.3. County/ parish |
37.4. Population of focus description (Describe; 500-character limit) |
37.5. What is the estimated number of individuals within your population of focus within the location listed?a |
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a The number of individuals within your population of focus is likely smaller than the total population in the location. For example, if 10,000 individuals live in the area (total population), but only 3,000 of those are in the target 12- to 20-year-old age group for this prevention intervention, your estimated target population is 3,000. If your target population for this prevention intervention is more specific (e.g., Hispanic high school students or non-college youth aged 18 to 20), your population of focus number would be even smaller (e.g., 200). Report your population of focus size as accurately as possible.
Questions in this section are only asked for each intervention categorized as a community-based process (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________ E (autofill from Question 28)
Service Type: ___________________________________________ E (autofill from Question 28)
For this sub-form, we are interested in community-based intervention-service type activities that you expect will enhance the ability of the community or prevention system to influence substance use. Community-based processes you describe here might include holding more specific meetings with or training key stakeholders and partners or other community members and organizations; developing prevention provider networks; reorganizing local agencies; reallocating community prevention funds; or formally changing how local organizations work together to prevent substance misuse.
Activities related to more general capacity building (e.g., training prevention staff, building stakeholder or partner relationships) or the general functioning of your organization (e.g., coalition meetings) should not be included here and are better described in the capacity-building section earlier in this instrument. Also, you should categorize trainings of environmental influencers such as physicians/pharmacists as environmental strategies for CSAP strategy type and complete that sub-form instead.
38. For this intervention-service type, did you do any work related to community-based processes (e.g., stakeholder/partner meetings, T/TA for community, reorganization of local agencies, or reallocation of community funds for prescription misuse prevention) during the past Federal Fiscal year? E
Yes
No (If selected, you will automatically proceed to the end of this sub-form.)
39. Indicate the number of stakeholder/partner meetings you held during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
meetings (If none, enter “0.”)
40. Indicate the number of stakeholders/partners you trained during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
stakeholders/partners trained (If none, enter “0.”)
41. Indicate the number of community members, other than stakeholders/partners, you trained during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
community members trained (If none, enter “0.”)
42. Indicate the number of community organizations to whom you provided training or technical assistance during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E
community organizations (If none, enter “0.”)
43. Did you develop a prescription drug misuse prevention provider network during the past Federal fiscal year for this intervention-service type? For example, you may have established a prescriber and dispenser group that meets regularly. (Select one response.)E
Yes
No, we do not yet have a network
No, a network was already in place
44. For this intervention-service type, during the past Federal fiscal year, did you help with reorganizing agencies to promote efficiency in delivering prescription drug misuse prevention services? (Select one response.)E
Yes
No
45. For this intervention-service type, during the past Federal fiscal year, did you reallocate other (non-SPF Rx) sources of funding to help support the goals of your SPF Rx effort? (Select one response.)E
Yes
No
46. For this intervention-service type, during the past Federal fiscal year, did you formally change the ways organizations work together to prevent prescription drug misuse —for example, by documenting specific policies or practices for working together? (Select one response.)E
Yes
No
47. For this intervention-service type, did you conduct other community activities during the past Federal fiscal year? (Select one response.)E
Yes (Describe.)
No
48. Estimate the total number of individuals in your population of focus who were indirectly reached or affected by this community-based process intervention-service type during the past Federal fiscal year. Approximately how many individuals were affected by the results of this intervention-service type? (Note: Because this is a population-based intervention, you are asked to estimate the number of people reached. In most cases, this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E
(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)
Enter the estimated number of individuals in the population of focus indirectly reached or affected by your implementation of this community-based process intervention during the past Federal fiscal year. (If none, enter “0.”) _____________________
49. Of the total number of participants reached by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total reported in Question 48. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E
49.1. Females: _____________
49.2. Males: ______________
49.3. Transgender: ______________
49.4. Other: _____________________________ (Specify: _____________________)
49.5. Gender unknown: ______________
50. Of the total number of participants reached by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 48. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
50.1. Children aged 0 to 11: _____________
50.2. Youth aged 12 to 17: _____________
50.3. Young adults aged 18 to 25: _____________
50.4. Adults aged 26 and older: _____________
50.5. Age unknown: ___________
51. Of the total number of participants reached by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 48. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
51.1. American Indian or Alaska Native: _____________
51.2. Black or African American: _____________
51.3. White: _____________
51.4. Asian: _____________
51.5. Native Hawaiian or Other Pacific Islander: ______________
51.6. Multiracial: ___________
51.7. Other: _____________
51.8. Race unknown: ___________
52. Of the total number of participants reached by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 48. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
52.1. Hispanic, Latino/a, or of Spanish origin: ____________
52.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
52.3. Hispanic ethnicity unknown: ____________
Questions in this section are only asked for each intervention categorized as a prevention education intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________E (autofill from Question 28)
Service Type: ___________________________________________ E (autofill from Question 28)
This sub-form should focus on prevention education intervention-service types that involve two-way communication between an educator or facilitator and participants. Prevention education intervention-service type activities focus on improving critical life and social skills, such as decision-making, refusal, critical analysis of media messages, and judgment. These activities include classroom sessions for all ages, parenting and family management classes, and peer leader programs. Prevention education typically uses curriculum-based materials.
The activities included under prevention education should focus on more than just providing information to participants, such as through a community presentation or disseminating brochures or other materials; these types of one-way communication activities should be categorized as and described under information dissemination. Please categorize trainings of environmental influencers such as physicians/pharmacists as environmental strategies for CSAP strategy type in item 28 and complete that sub-form instead.
53. Indicate the type(s) of participants served by this prevention education intervention during the past Federal fiscal year (Select all that apply.)E
Middle school students
High school students
College students
Parents
Employees (i.e., recipients of a workplace substance misuse prevention program)
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
54. What was the average number of sessions provided for each group of participants in the prevention education intervention during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
___ sessions
55. What was the average length of the individual sessions, in hours, during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
___ hours
56. How many total participants were served by this prevention education intervention during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
(Note: In most cases, this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E
(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)
Enter the estimated number of individuals in the population of focus served by your implementation of this prevention education intervention during the past Federal fiscal year. (If none, enter “0.”) _____________________
___ participants
(If
none, enter “0”—you will automatically proceed to
the end of this sub-form.)
57. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 56. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E
57.1. Females: _____________
57.2. Males: ______________
57.3. Transgender: ______________
57.4. Other: _____________________________ (Specify: _____________________)
57.5. Gender unknown: ______________
58. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 56. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
58.1. Children aged 0 to 11: _____________
58.2. Youth aged 12 to 17: _____________
58.3. Young adults aged 18 to 25: _____________
58.4. Adults aged 26 and older: _____________
58.5. Age unknown: ___________
59. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 56. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
59.1. American Indian or Alaska Native: _____________
59.2. Black or African American: _____________
59.3. White: _____________
59.4. Asian: _____________
59.5. Native Hawaiian or Other Pacific Islander: ______________
59.6. Multiracial: ___________
59.7. Other: _____________
59.8. Race unknown: ___________
60. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 56. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
60.1. Hispanic, Latino/a, or of Spanish origin: ____________
60.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
60.3. Hispanic ethnicity unknown: ____________
Questions in this section are only asked for each intervention categorized as an alternative drug-free activity intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________E (autofill from Question 28)
Service Type: ___________________________________________ E (autofill from Question 28)
This sub-form should focus on alternative drug-free activities, including recognition and drug-free leisure activities implemented as a means of halting or reducing substance misuse. Alternative programs include a wide range of activities that appeal to children and youth: athletics, art, music, movies, and community service projects. Related intervention-service type activities often provide youth who live in high-risk communities with safe alternative environments and opportunities to develop relationships with non-substance-using peers.
61. Indicate the type(s) of participants served by this alternative drug-free activity strategy during the past Federal fiscal year. (Select all that apply.)E
Middle school students
High school students
College students
Parents
Employees (i.e., recipients of a workplace substance misuse prevention program)
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
62. Are the alternative activities targeted at identifiable participants (e.g., student clubs, mentoring) or with events for populations as a whole (e.g., drug-free events, festivals/fairs, drop-in activities)? (Select all that apply.)E
Identifiable participants (If selected, you will complete Questions 63-64.)
Populations as a whole (If selected, you will complete Questions 65-66.)
Questions for alternative activities targeted at identifiable participants
63. What was the average number of sessions provided for each group of participants in this alternative drug-free activity during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ session(s)
64. What was the total number of hours provided for each group of participants in this alternative drug-free activity during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ hour(s)
Questions for alternative activities delivered to populations as a whole, not identifiable participants
65. What type(s) of the alternative activity events that were not targeted to identifiable participants did you implement during the past Federal fiscal year? (Select all that apply.)E
Concert
Festival or fair
Sporting event
Picnic
Drop-in activity
Web-based gathering
Other (Describe.)
66. How many separate alternative activity events that were not targeted to identifiable participants were conducted during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ event(s)
67. How many total participants were served by this set of alternative drug-free activities during the past Federal fiscal year? This response should be written as a whole number. Try to count each individual only once (e.g., 4). (Note: this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E
(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)
________ participants
(If
none, enter “0”—you will automatically proceed to
the end of this sub-form.)
68. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total number of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
68.1. Females: _____________
68.2. Males: ______________
68.3. Transgender: ____________________
68.4. Other: ___________________________ (Specify: _______________________)
68.5. Gender unknown: _______________
69. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
69.1. Children aged 0 to 11: _____________
69.2. Youth aged 12 to 17: _____________
69.3. Young adults aged 18 to 25: _____________
69.4. Adults aged 26 and older: _____________
69.5. Age unknown: _____________
70. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
70.1. American Indian or Alaska Native: _____________
70.2. Black or African American: _____________
70.3. White: _____________
70.4. Asian: _____________
70.5. Native Hawaiian or Other Pacific Islander: ______________
70.6. Multiracial: ___________
70.7. Other: _____________
70.8. Race unknown: ___________
71. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
71.1. Hispanic, Latino/a, or of Spanish origin: ____________
71.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
71.3. Hispanic ethnicity unknown: ____________
Questions in this section are only asked for each intervention categorized as a problem identification and referral intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________E (autofill from Question 28)
Service Type: ___________________________________________ E (autofill from Question 28)
This sub-form should focus on problem identification and referral activities that aim to identify those who have engaged in illegal or age-inappropriate use of alcohol, first use of illicit drugs, and nonmedical use of prescription drugs to reverse or stop the behavior. It may include screening programs to identify individuals in need of services, including online screening and feedback programs or employee and student assistance programs.
72. Indicate the type(s) of participants served by this Problem Identification and Referral prevention intervention during the past Federal fiscal year. (Select all that apply.)E
Middle school students
High school students
College students
Parents
Employees (i.e., recipients of a workplace substance misuse prevention program)
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
73. Where did this problem identification and referral activity take place during the past Federal fiscal year? (Select all that apply.)E
School
Health care facilities
Jails or prisons
Courts
Workplace or workplace program
Other (Describe.)
74. What type(s) of services were individuals referred to during the past Federal fiscal year? (Select all that apply.)E
Substance use treatment
Mental health treatment
Substance use prevention activities
Housing services
After-school activities
Transportation
Day care or adult care services
Health care
Other (Describe.)
75. What was the total number of individuals served by the problem identification and referral services provided during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E (Note: In most cases, this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E
(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)
Enter the estimated number of individuals in the population of focus served by your implementation of this problem identification and referral intervention during the past Federal fiscal year. (If none, enter “0.”)
________ individuals
(If
none, enter “0”—you will automatically proceed to
the end of this sub-form.)
76. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 75. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E
76.1. Females: _____________
76.2. Males: ______________
76.3. Transgender: ______________
76.4. Other: _____________________________ (Specify: _____________________)
76.5. Gender unknown: ______________
77. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 75. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
77.1. Children aged 0 to 11: _____________
77.2. Youth aged 12 to 17: _____________
77.3. Young adults aged 18 to 25: _____________
77.4. Adults aged 26 and older: _____________
77.5. Age unknown: ___________
78. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 75. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
78.1. American Indian or Alaska Native: _____________
78.2. Black or African American: _____________
78.3. White: _____________
78.4. Asian: _____________
78.5. Native Hawaiian or Other Pacific Islander: ______________
78.6. Multiracial: ___________
78.7. Other: _____________
78.8. Race unknown: ___________
79. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 75. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
79.1. Hispanic, Latino/a, or of Spanish origin: ____________
79.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
79.3. Hispanic ethnicity unknown: ____________
Questions in this section are only asked for each intervention categorized as an environmental strategy intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________E (autofill from Question 28)
Service Type: ___________________________________________ E (autofill from Question 28)
This sub-form should focus on environmental strategies that establish or change community conditions to influence substance misuse. Approaches may center on policy, regulatory, or legal changes or implementation; efforts to maximize enforcement of laws or policies related to prescription drugs; organizational-level policy change; safe storage and disposal activities; or training of those able to directly influence environmental conditions, such as health care professionals, pharmacists, and law enforcement.
Note that you should report all media and communication campaigns as information dissemination and all parent education programs as prevention education for CSAP strategy type in item 28. Note that if you conduct an information dissemination campaign to promote use of existing prescription drug drop boxes, you would report that in the information dissemination sub-form. In this section, you would report on the installation of new drop boxes.
Throughout this section, refer to your organization or partners with your organization. For example, if you worked with the police department on diversion, you would report it on this form.
In this section, report strategies that include providing training and individual education for those in positions to affect prescription drug misuse through policy, prescribing and dispensing practices, enforcement, communication, and so on (e.g., health care providers, pharmacists, law enforcement officers, school employees). Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities for other environmental strategies that you have listed as separate environmental strategies.
80. Did this environmental strategy include training or individual education (e.g., “detailing”) with environmental Influencers—those in positions to affect prescription drug misuse through policy, enforcement, communication, and so on (e.g., health care providers, pharmacists, law enforcement officers, school employees)—during the past Federal fiscal year? (Select all that apply.)E
Yes, group training of environmental influencers (If selected, you will answer Questions 81, 82, 83, and 85.)
Yes, individual one-on-one education of environmental influencers (If selected, you will answer Questions 81, 84, and 85.)
No (If selected, you will skip Questions 81-85.)
81. To which types of environmental influencers did you provide training or individual education to affect prescription drug misuse through policy, enforcement, communication, and so on during the past Federal fiscal year? (Select all that apply.)E (autofill after first completed)
Health care providers/medical community
Dentists/dental community
Veterinarians/veterinary community
Pharmacists/pharmacy community
Insurers
School employees or administrators
Law enforcement
Other policymakers such as elected officials
Tribal leaders or elders
Business owners or employees
Service or civic organization employees or administrators
Media members
Military personnel or veterans’ organizations
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
Other (Describe.) ______________________________________________________
82. How many training sessions were conducted for each group of environmental influencers during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ sessions
83. What was the average length of the group training sessions, in hours, during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ hours
84. What was the average length of time spent with individuals on one-on-one education of environmental influencers, in hours during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ hours
85. How many total individuals participated in group training or individual education of environmental influencers during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ individuals participated in group training of environmental influencers
________ individuals participated in individual education of environmental influencers
In this section report on what you did through this SPF Rx environmental strategy related to policy, regulation, or law enactment or implementation at either the state level or with organizations at the local level. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities for other environmental strategies that you have listed as separate environmental strategies.
86. During the past Federal fiscal year, did your SPF Rx environmental strategy include any policy, regulation, or law enactment or implementation? This would include changing, implementing, or strengthening the implementation of new laws at the state level or working with organizations at the local level to develop or implement policies to advance the goals of SPF Rx (e.g., help health care provider organization institute policies to follow CDC guidelines for prescribing opioids). (Select one response.)E
Yes
No (If selected, you will skip Questions 87-93.)
87. During the past Federal fiscal year, did you do any work related to changing or implementing laws, regulations, government policies, or licensing requirements as part of your SPF Rx efforts? For example, this could involve state laws related to the use of PDMP data or to opioid prescribing practices.E
Yes
No (If selected, you will skip Questions 88-90.)
88. What types of activities were you engaged in during the past Federal fiscal year to support enactment or implementation of laws, regulations, governmental policies, or licensing requirements? (Select all that apply.)E
Met with elected officials or policymakers to educate them on the policy issues
Conducted research or analysis of policy options for officials or policymakers
Informed key stakeholders and institutions about the new policy, law, or requirement
Coordinated activities or meetings with key stakeholders and organizations
Developed informational materials (fliers, postcards, websites) related to the new policy, law, or requirement
Distributed informational materials (fliers, postcards, websites) related to the new law/policy/requirement
Other activities (Describe.)
Other activities (Describe.)
Other activities (Describe.)
89. Indicate which of the following laws, regulations, government policies, or licensing requirements you worked on during the past Federal fiscal year as part of your SPF Rx effort. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities that are part of other environmental strategies that you have listed as separate interventions. Note that some items will only be applicable to the primary grantee or the subrecipient, depending on whether they are state or local types of activities. For example, state-level grantees may be more involved in state-level legislative issues (e.g., prescription drug monitoring program [PDMP] laws) than subrecipient communities are.
Please check the boxes below for any specific laws, regulations, government policies, or licensing requirements that you worked on during the past year. Then indicate whether your activities related to change (enactment) or implementation of the new law, regulation, governmental policy, or licensing requirement (or both). (Select all that apply.)E
Require universal prescriber registration with the PDMP
Involved with changing policy or law
Involved with implementation
Allow doctors to assign authorized delegates to access PDMP data
Involved with changing policy or law
Involved with implementation
Require participation in the PDMP for new types of prescribers (e.g., dentists, veterinarians)
Involved with changing policy or law
Involved with implementation
Have state rules that delineate circumstances when prescribers must query the PDMP for their patients’ history of opioid prescriptions
Involved with changing policy or law
Involved with implementation
Require that pharmacists upload opioid dispensing data more quickly (e.g., within 24 hours)
Involved with changing policy or law
Involved with implementation
Expand the scope of data reported to PDMP by pharmacists (e.g., source of payment)
Involved with changing policy or law
Involved with implementation
Allow expansion of PDMP data access to allow use for public health surveillance, prevention, and research
Involved with changing policy or law
Involved with implementation
Develop interstate agreements to share PDMP data (e.g., facilitate providers’ ability to query PDMPs of neighboring states)
Involved with developing policy
Involved with implementation of new policy
Create a linkage between patients’ PDMP records and their electronic health records
Involved with developing policy
Involved with implementation of new policy
Change the algorithm by which patients with similar names and other characteristics are aggregated
Involved with developing policy
Involved with implementation of new policy
Produce regular reports from the PDMP that summarize key state, regional, or local statistics of interest
Involved with developing policy
Involved with implementation of new policy
Produce unsolicited reports from the PDMP
Involved with developing policy
Involved with implementation of new policy
For which group are the new unsolicited reports? (check all that apply):
Prescribers (Describe purpose.) ________________________________________
Dispensers (Describe purpose.) _________________________________________
Licensing boards (Describe purpose.) ____________________________________
Law enforcement agencies (Describe purpose.) ____________________________
Other group (Specify and describe purpose.) ______________________________
Mandate prescriber training on safe opioid prescribing
Involved with changing policy, regulation, or medical licensing board requirement
Involved with implementation of new requirement
Limit dose of opioid prescription (e.g., 90 MME/day) without special approval
Involved with changing state guidelines or state insurance/Medicaid pharmacy policy
Involved with implementation of new guidelines/policies
Limit duration of opioid prescription for chronic noncancer pain patients without special approval
Involved with changing state guidelines or state insurance pharmacy policies
Involved with implementation of new guidelines/policies
Require pain clinics to be regularly certified by state medical board
Involved with changing law/regulations, policy, or medical board requirement
Involved with implementation of new requirement
Require pain clinics to be owned and operated by licensed physicians
Involved with changing law/regulations, policy, or medical board requirement
Involved with implementation of new requirement
Other regulations, laws, or government policies related to SPF Rx that you worked on in the past year. (Describe. 3,000-character limit)
Involved with changing law/policy
Involved with implementation
90. Describe any new laws, regulations, licensing requirements, or government policies that were enacted, established, or implemented during the past Federal fiscal year related to this particular environmental strategy.E (3,000-character limit)
91. Did you work with individual organizations (e.g., local hospitals, local primary care organizations, pharmacies, insurers) during the past Federal fiscal year to help them to develop or implement organizational policies related to SPF Rx goals? E
Yes
No (If selected, you will skip Questions 92 and 93.)
92. Please check the boxes below to indicate any SPF Rx program activities you carried out during the past Federal fiscal year related to helping institutions develop or implement organizational policies. (Select all that apply.)E
Worked with medical organizations to incorporate or implement policies to register health care providers/prescribers with the PDMP
Worked with medical organizations to incorporate or implement policies requiring their medical providers to query their patients’ PDMP records before prescribing opioids
Worked with pharmacy organizations to incorporate or implement policies to improve timeliness of PDMP upload
Worked with organizations to incorporate or implement policies to improve scope or quality of PDMP data
Worked with organizations to establish policies or agreements related to linkage of patient PDMP records with patient electronic health records (EHRs)
Worked with organizations to establish or implement policies or agreements related to linkage of PDMP data with vital records (deaths) or overdose data (e.g., emergency room visits or hospital admissions)
Worked with organizations to incorporate or implement policies to increase PDMP access or ease of use
Helped institutions implement/incorporate national CDC (or similar state) prescribing guidelines into their rules and codes
Helped institutions incorporate alternatives to opioids for pain treatment
Helped medical or pharmacy schools to incorporate prescription drug/opioid misuse prevention-related education into their curricula
Helped organizations with pharmacy benefit strategy change (e.g., institute drug utilization reviews for high-dose opioids)
Helped pharmacies with policies related to querying PDMP for risky prescription patterns
Helped with organizational policies related to social access, including safe storage and disposal of prescription drugs (e.g., help develop policies to facilitate broader distribution of home lock boxes to individuals filling prescriptions for opioids/controlled substances)
(Describe.)
Collaborated with organizations (e.g., medical regulatory bodies, law enforcement) to develop enforcement policies related to pain clinics
Collaborated with medical authorities (e.g., medical board/association) to develop policies to send letters to health care providers with higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP data
93. Describe any other work you did in the past Federal fiscal year related to helping individual organizations develop or implement policies that advance SPF Rx goals. (3,000-character limit).E _________________________________________________________________________
This section relates to the implementation of enforcement activities. (Development of new enforcement-related policies should be reported in the policy section.) Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate environmental strategies.
94. Did your environmental strategy include implementation of enforcement efforts (e.g., collaboration with law enforcement or medical/pharmaceutical authorities to respond to possible prescription drug diversion) during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Questions 95 and 96.)
95. Indicate which of the following activities you worked to implement during the past Federal fiscal year related to enforcement. (Select all that apply.)E
Collaborated with organizations (e.g., pharmacies, law enforcement) to prevent or respond to suspected diversion
Collaborated with organizations to enforce policies, laws, or regulations related to pain clinics
Collaborated with organizations to enforce policies or guidelines related to opioid prescribing
Collaborated with organizations to send letters or reports to health care providers with higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP data
Other major enforcement-related practices or activities in the past year (Describe; 3,000‑character limit.)
96. For this environmental strategy of enforcement, did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community) during the past Federal fiscal year? (Select one response.)E
Yes
No
This section relates to the implementation of environmental strategies related to safe storage or disposal of prescription drugs. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate environmental strategies.
97. During the past Federal fiscal year, did you work on any environmental strategies related to safe storage or disposal of prescription drugs?E
Yes
No (If selected, you will skip Questions 98-101.)
98. How many prescription drop boxes were already in your target geographic area before you began your SPF Rx 2021 grant)? E (autofill after first completed) __________
99. During the past Federal fiscal year, how many prescription drug boxes did you install in law enforcement agencies, pharmacies, and other locations? Enter total for each type of location.E
_________ installed in law enforcement agencies
_________ installed in pharmacies
_________ installed other locations
100. How many prescription drug take-back events did you organize, support, or participate in during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E _________
101. During the past Federal fiscal year, did you engage in any other safe storage or disposal activities related to prescription drugs (e.g., increase the distribution or access to home lock boxes or Deterra bags)? E
Yes (Describe; 3,000-character limit.) ____________________________________
No
102. During the past Federal fiscal year, did you engage in any other activities related to this intervention that did not fall into the categories of safe storage/disposal, policy, enforcement, or training of environmental influencers? Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities for other environmental strategies that you have listed as separate environmental strategies.E
Yes (Describe; 3,000-character limit.)
No
The questions in this section collect information on the individuals ultimately reached or affected through your training of environmental influencers, enforcement efforts, policy-related activities, safe storage/disposal, or other activities. This goes beyond the number of individuals directly involved in the training, policy change, or enforcement to estimate the numbers affected in the targeted population in your entire community. This set of questions specifically refers to [NAME OF INTERVENTION-SERVICE TYPE ACTIVITY].
103. Estimate the total number of individuals who were reached or affected by your environmental strategy during the past Federal fiscal year. If you are unsure of the exact number of individuals affected, respond with your best estimate. This response should be written as a whole number (e.g., 4). (Note: this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E
(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)
_________ total individuals (If none, enter “0.”—you will automatically proceed to the end of this sub-form.)
104. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 103. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E
104.1. Females: _____________
104.2. Males: ______________
104.3. Transgender: ______________
104.4. Other: _____________________________ (Specify: _____________________)
104.5. Gender unknown: ______________
105. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 103. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
105.1. Children aged 0 to 11: _____________
105.2. Youth aged 12 to 17: _____________
105.3. Young adults aged 18 to 25: _____________
105.4. Adults aged 26 and older: _____________
105.5. Age unknown: ___________
106. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 103. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
106.1. American Indian or Alaska Native: _____________
106.2. Black or African American: _____________
106.3. White: _____________
106.4. Asian: _____________
106.5. Native Hawaiian or Other Pacific Islander: ______________
106.6. Multiracial: ___________
106.7. Other: _____________
106.8. Race unknown: ___________
107. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 103. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
107.1. Hispanic, Latino/a, or of Spanish origin: ____________
107.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
107.3. Hispanic ethnicity unknown: ____________
Questions in this section are only asked for each intervention categorized as an information dissemination intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)
Name of Prevention Intervention: _________________________________E (autofill from Question 28)
Service Type: ___________________________________________ E (autofill from Question 28)
This sub-form focuses on information dissemination activities to change community attitudes, build awareness of substance use issues to reduce their incidence and prevalence, and change behavior. The strategy is characterized by one-way communication from source to audience. Report all media and communication campaigns (e.g., social marketing campaigns) in this section.
Please report on information dissemination activities that directly relate to educating policymakers about policies, laws, or regulations as environmental strategies for CSAP strategy type in item 28 and complete that sub-form. Note that publicity for specific environmental strategies (e.g., fliers to promote the installation of a new prescription drug box or a drug take-back day) should not be reported as a separate information dissemination activity. However, if you conduct an information dissemination campaign to promote use of existing prescription drug drop boxes, you would report that in this Information Dissemination sub-form.
108. What was/were the intended purpose(s) of the communication or information that you disseminated for this service type? (Select all that apply.)E
To raise awareness of prescription drug misuse problems in the community
To gain support from the community for prescription drug misuse prevention efforts
To provide information on community norms related to prescription drug misuse
To provide information on the dangers of sharing medications and misusing prescription drugs
To provide prescription drug misuse prevention information (e.g., information on securing prescription drugs in the household, information on resisting offers for sharing prescription/pharmaceutical drugs)
To change individual behaviors with regard to prescription drug misuse
To provide prevention intervention program information (e.g., contact information, meeting times)
To provide surveillance and monitoring information (e.g., information about whom to contact if you suspect prescription drug diversion)
To provide a directory of community resources for prevention of prescription drug misuse
Other (Describe.)
109. For this intervention-service type activity, indicate the community members and groups (i.e., target audience) to whom you disseminated the information during the past Federal fiscal year. (Select all that apply.)E
Health care providers/medical community
Pharmacists/pharmacy community
The general public
Youth groups or representatives
Schools or school districts
Youth-serving organizations other than schools (e.g., Big Brothers/Big Sisters, Boy Scouts/Girl Scouts)
Parents, family, or caregiver groups
Organizations serving seniors/older population
Advocacy volunteers
Business community
Media (e.g., radio and television stations, newspapers and magazines)
Faith-based organizations (e.g., churches, charitable organizations with religious affiliations such as Catholic Charities)
Civic or volunteer organizations (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)
LGBTQ-supportive organization
Military or veteran organization
Law enforcement agencies (e.g., local, tribal, state, and Federal law enforcement agencies, including the police, the Federal Bureau of Investigation [FBI], and the Drug Enforcement Administration [DEA])
Local or state, tribal, or jurisdiction courts
State departments of justice (e.g., judicial department, department of juvenile justice, department of criminal justice, attorney general’s office)
State, tribal, or local jails and prisons
State, tribal, jurisdiction, or local public health departments
Mental health professionals or agencies
Other state, tribal, or jurisdiction government agencies (e.g., public health, public safety, social services, American Indian tribal government)
Local, village, or tribal agencies (mayor’s office, city council, tribal council, Alaska Native Corporation agencies)
Other (Describe.)
110. Indicate the type(s) of individuals targeted by this information dissemination activity during the past Federal fiscal year. (Select all that apply.)E (autofill after first completed)
Middle school students
High school students
College students
Parents
Health care providers
Employees
Current or former military members
Military family members
Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)
Individuals living in poverty
Individuals whose native language is other than English
Individuals with low literacy
Individuals with mental illness
Individuals with disabilities (e.g., hearing, visually, or physically impaired)
Other (Describe.)
111. For this information dissemination activity, did you create or air television ads during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Questions 112-115.)
112. How many individual times did the television ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ times
113. How many weeks did the television ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ weeks
114. How many different televisions stations aired the ads during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ stations
115. Provide any information you have on the reach of the television ads aired during the past Federal fiscal year. This could include information provided by the television stations or advertising agency on ratings points; the average number of viewers at the time the ads aired; the geographic area where the ads aired; and the target audience of the related television programs.E
(Describe; 3,000-character limit.)
116. For this information dissemination activity, did you create or air radio ads during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Questions 117-120.)
117. How many individual times did the radio ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ times
118. How many weeks did the radio ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ weeks
119. How many different radio stations aired the ads during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E
________ stations
120. Provide any information you have on the reach of the radio ads aired during the past Federal fiscal year. This could include information provided by the radio stations or advertising agency on ratings points; the average number of listeners at the time the ads aired; the geographic area where the ads aired; and the target audience of the related radio broadcast.E
(Describe; 3,000-character limit.)
121. For this information dissemination activity, did you create or publish print ads during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Questions 122-124.)
122. How many individual times did the print ads run during the past Federal fiscal year? (Select one response.) Insert “0” if ads were created but not distributed during the period. This response should be written as a whole number (e.g., 4).E
________ times
123. How many different newspapers or magazines displayed the ads during the past Federal fiscal year? Insert “0” if ads were created but not distributed during the period. This response should be written as a whole number (e.g., 4).E
________ newspapers or magazines
124. Provide any information you have on the reach of the print ads run during the past Federal fiscal year. This could include information provided by the newspaper or magazine on its average readership; the geographic area in which the publication was distributed; and the target audience of the publication.E
(Describe; 3,000-character limit.)
125. For this information dissemination activity, how many special events (e.g., invited speakers) were hosted during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ special events
126. For this information dissemination activity, how many other promotional activities (e.g., distributing prescription drug take-back information at a health fair) were implemented during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ promotional activities
127. For this information dissemination activity, did you present at community meetings (e.g., parent-teacher association [PTA] meetings, town hall meetings, school assemblies) during the past Federal fiscal year? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select one response.)E
Yes
No (If selected, you will skip Questions 128 and 129.)
128. How many community meetings did you present at during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ meetings
129. What was the total number of participants at all community meetings where you presented during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ participants
130. For this information dissemination activity, did you send any letters to the editor of the local newspaper or community newsletters during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Question 131.)
131. How many letters were published during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ letters
132. For this information dissemination activity, did you produce or distribute prescription drug misuse prevention posters during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Question 133.)
133. How many posters were distributed during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
________ posters
134. For this information dissemination activity, did you produce or distribute prescription drug misuse prevention brochures during the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Question 135.)
135. How many brochures were distributed during the past Federal fiscal year? This response should be written as a whole number (e.g., 50).E
________ brochures
136. For this information dissemination activity, did you provide a related information line or hotline in the past Federal fiscal year? (Select one response.)E
Yes
No (If selected, you will skip Question 136.)
137. How many individuals called into the information line or hotline in the past Federal fiscal year? This response should be written as a whole number (e.g., 50).E
________ individuals
138. For this information dissemination activity, did you develop or run a prescription drug misuse prevention-focused clearinghouse or information resource center in the past Federal fiscal year? (Select one response.) E
Yes
No
139. For this information dissemination activity, during the past Federal fiscal year, did you launch or maintain any web sites or post information on social media platforms focused on prescription drug misuse prevention? (Select all that apply.)E
Web site(s)
TikTok
Tumblr
Snapchat
Other (Specify.) ___________
No (If selected, you will skip Question 140.)
140. What is the number of visitor sessions (visits) or interactions (e.g., likes, retweets, shares) that the web sites and platforms, had during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E
Specify number of visits/interactions _____
Do not know
141. For this information dissemination activity, did you conduct other communication activities during the past Federal fiscal year? E
Yes (Describe; 3,000-character limit.)
No
142. Estimate the total number of individuals who were reached or affected by these information dissemination activities for during the past Federal fiscal year. If you are unsure of the exact number of individuals affected, respond with your best estimate. This response should be written as a whole number (e.g., 4). (Note: this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E
(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)
________ (If none, enter “0”—you will automatically proceed to the end of this sub-form)
143. Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 142), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 142. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E
143.1. Females: _____________
143.2. Males: ______________
143.3. Transgender: ______________
143.4. Other: _____________________________ (Specify: _____________________)
143.5. Gender unknown: ______________
144.Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 142), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 142. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
144.1. Children aged 0 to 11: _____________
144.2. Youth aged 12 to 17: _____________
144.3. Young adults aged 18 to 25: _____________
144.4. Adults aged 26 and older: _____________
144.5. Age unknown: ___________
145.Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 142), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 142. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
145.1. American Indian or Alaska Native: _____________
145.2. Black or African American: _____________
145.3. White: _____________
145.4. Asian: _____________
145.5. Native Hawaiian or Other Pacific Islander: ______________
145.6. Multiracial: ___________
145.7. Other: _____________
145.8. Race unknown: ___________
146. Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 142), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 142. These responses should be written as whole numbers (e.g., 4) and not as percentages.E
146.1. Hispanic, Latino/a, or of Spanish origin: ____________
146.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________
146.3. Hispanic ethnicity unknown: ____________
Questions in this section are only asked if at least one intervention is categorized as active, inactive, completed or discontinued in the past federal fiscal year (see Q28g)
In this section, we would like to learn about challenges to implementing SPF Rx interventions in your community during this reporting period.
147.How much did the following factors impact the progress or results of your SPF Rx efforts related to implementing interventions listed below in the past Federal fiscal year?E
Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you should check the box “No impact.”
Factors Impacting Intervention Implementation E |
No impact |
Low impact |
Moderate impact |
High impact |
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This section collects information on how you used your monitoring and evaluation findings.
148. Have you made changes to your SPF Rx prevention interventions or the implementation of your prevention interventions during the past Federal fiscal year as the result of the analysis of your monitoring and evaluation data? (Select one response.)E
Yes
No (If selected, you will skip Question 149.)
Data not yet collected or analyzed (If selected, you will skip Question 149.)
149. Which prevention intervention(s) did you modify—and how—during the past Federal fiscal year as the result of the analysis of your monitoring and evaluation data? E autofill with responses from 28a
Changed intervention (Select all that apply.):
[INTERVENTION NAME HERE] (Describe change.) ___________________________________________
[INTERVENTION NAME HERE] (Describe change.) ___________________________________________
[INTERVENTION NAME HERE] (Describe change.) ___________________________________________
[INTERVENTION NAME HERE] (Describe change.) ___________________________________________
[INTERVENTION NAME HERE] (Describe change.) ___________________________________________
150. Did you or your local evaluator work on any of the following intervention evaluation activities related to process or outcomes evaluation of your SPF Rx interventions during the past Federal fiscal year? Process evaluation focuses on how an intervention was implemented and operates. Outcome evaluation looks at the effect of your interventions on your targeted consumption, consequence, or intervening variables. (Select all that apply.) E
We did not conduct evaluation activities related to SPF Rx during the past Federal fiscal year
Evaluation activity |
Process evaluation |
Outcome evaluation |
150.1. Develop or substantially revise an evaluation plan |
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150.2. Collect data |
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150.3. Analyze data |
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150.4. Produce an evaluation report |
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150.5. Not applicable; no work done in past Federal fiscal year |
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Questions in this section are only asked if at least one evaluation activity is marked as having been worked on in the past Federal Fiscal year (see Q150)
In this section, we would like to learn about challenges that had an impact on evaluating prevention interventions in your community during this reporting period.
151. How much did the following factors impact the progress or results of your SPF Rx efforts related to evaluating prevention interventions in the past Federal fiscal year?E
Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you should check “No impact.”
Factors Impacting Intervention Evaluation E |
No impact |
Low impact |
Moderate impact |
High impact |
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In this section, we would like to learn about broad contextual factors that have had an impact on SPF Rx activities and outcomes in your community, state, tribal area, or jurisdiction during this reporting period.
152. How much impact did the following factors have on the progress or results of your SPF Rx efforts during the past Federal fiscal year? (Select one level of impact for each factor.)E
Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you should check the box “No impact.”
SPF Rx108. Broader Contextual Factors |
No impact |
Low impact |
Moderate impact |
High impact |
152.1. Lack of available mental health treatment (i.e., leading to self-medicating) |
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152.2. Lack of available substance use treatment |
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152.3. Lack of access to medical care and better treatment options for chronic medical conditions, including pain |
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152.4. Lack of community awareness of the risk factors, extent, or consequences of prescription drug/opioid misuse |
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152.5. Easy access to prescription drugs for misuse |
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152.6. Lack of trust in government agencies (i.e., public health authorities, social services, or law enforcement) |
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152.7. High poverty rates/low SES |
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152.8. High unemployment, underemployment, or economic dislocation |
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152.9. Low literacy or low education levels |
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152.10. Community social disorganization |
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152.11. Social isolation |
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152.12. Lack of opportunities for area youth |
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152.13. Cultural norms, attitudes, or practices favoring substance use |
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152.14. Cultural norms, attitudes, or practices that are resistant to identifying and serving individuals involved with substance use |
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152.15. Stigmatization of individuals involved in substance use in the community |
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152.16. Stressful events affecting large portions of the population of focus (e.g., natural disasters, COVID-19 related closures, other unexpected traumatic community events) (Describe.) _________________ |
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152.17. Historical trauma experienced by racial/ethnic groups |
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152.18. Other
(Describe.)
__________________ |
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152.19. Other
(Describe.)
__________________ |
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152.20. Other
(Describe.)
__________________ |
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153. Provide any additional comments about your SPF Rx–related prevention intervention activities here. (Describe; 3,000-character limit.) E
154. Do you have any additional comments about any aspects of the SPF Rx Initiative? (Describe; 3,000-character limit.) E
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CLI Part 1 Revision |
| Author | DACCC |
| File Modified | 0000-00-00 |
| File Created | 2023-08-27 |