Form 1a Implementation Measures

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures

SERVICE AREA AND CONSORTIUM
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Measure Instructions
Identify the number and types of medical
organizations and agencies in your
consortium.

Measure
• Hospital - Critical Access Hospital (CAH)
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Hospital - Small Rural (49 beds or less,
non-CAH)
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Hospital - Other (e.g., Sole Community,
Rural Referral Center, etc.)
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Emergency medical services entity
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Federally Qualified Health Center (FQHC)
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FQHC Look-alike
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Local or state health department
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Mental and behavioral health
organization, practice, or provider
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Primary care practice or provider
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Rural Health Clinic
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Ryan White HIV/AIDS clinic
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Substance abuse treatment provider –
Methadone clinic
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Substance abuse treatment provider –
Opioid treatment program (OTP)
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Substance abuse treatment provider –
Other
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Other medical agency or organization,
Type 1- Specify:
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Other medical agency or organization,
Type 2- Specify
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Other medical agency or organization,
Type 3- Specify

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Identify the number and types of social
service and non-medical organizations and
agencies in the consortium

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Community-based organization
Cooperative extension system office
Criminal justice entity – Law enforcement
Criminal justice entity – Court system
Criminal justice entity - Prison
Criminal justice entity – Probation and
parole
Faith-based organization
Healthy Start site
HIV and HCV prevention organization

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures
Maternal, Infant, and Early Childhood
Home Visiting Program local
implementation agency
• Poison Control Center
• Primary Care Association (PCA)
• Primary Care Organization (PCO)
• Recovery Community Organization(RCO)
• Research / Academic Organization
• School system
• Single State Agency (SSA)
• State Office of Rural Health (SORH)
• Tribe/Tribal organization
• Other social service and non-medical
agency or organization, Type 1Specify
• Other social service and non-medical
agency or organization, Type 2Specify
• Other social service and non-medical
agency or organization, Type 3specify
• Single County
• Multiple Counties
• State
• Multiple States
• National
Total population in the project’s rural service
area
Total number of consortium meetings
conducted in the current reporting period
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Select the option that best describes your
project’s service area

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Please report the total number of people
that live in the project’s rural service area.
Please report the total number of
consortium meetings conducted in the
current reporting period in which the
majority (>75%) of members participated.
Please report the total unduplicated number
of service delivery sites within the
Consortium in the target rural service area
offering at least one prevention, treatment
and/or recovery service within the current
reporting period.

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For each of the following services, please
report the total number of service delivery
sites within the consortium in the target
rural service area that offered that service
within the current reporting period. If no
service delivery sites offered the service,
please input 0.

Total number of unduplicated service delivery
sites offering at least one prevention,
treatment and/or recovery service

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Prevention services(not including
naloxone)
Screening and/or assessment services
Medication-Assisted Treatment (with
or without psychosocial)
SUD/OUD treatment other than MAT
Infectious disease testing (i.e., HIV or HCV)
Recovery support services
Mental health treatment

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures

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Report the total unduplicated number of
service delivery sites within the consortium
in the target rural service area offering at
least one harm reduction service within the
current reporting period.
For each of the following harm reduction
services, please report the total number of
service delivery sites within the consortium
in the target rural service area that offered
that service within the current reporting
period. If no service delivery sites offered
the service, please input 0.
For each service listed, select whether it was
newly established with or without RCORPImplementation Support funds, expanded
with or without RCORP-Implementation
funds, remained the same, or did not exist in
the current reporting period (dropdown).

NOTE: Sustainability measures only
reported in final reporting period ofthe
grant (Sept. 2024)
Will the consortium as a unit and/or at least
one key consortium activity be sustained
after the RCORP grant ends?
If you selected yes in previous sub-section,
what will sustain? (check all that apply)
If you selected “At least one key consortium
activity” in the previous sub-section how will
the activity or activities be sustained?
(check all that apply)

• Other - specify
Total number of unduplicated service delivery
sites offering at least one harm reduction
service
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Naloxone access
Syringe services
Fentanyl test strips
Safe smoking kits
Sex worker services
Other - specify

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Prevention service (any except naloxone)
Screening and/or assessment service
MAT (with or without psychosocial therapy)
SUD/OUD treatment other than MAT
Mental health treatment
Infectious disease testing (i.e., HIV or HCV)
Recovery support services (any)
Harm reduction services (any)
Other – please specify
Yes
No

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Consortium as a unit
At least one key consortium activity
Absorption of services or other means of inkind support
Reimbursement by third party payers
RCORP grant funding
HRSA grant funding (not including RCORP
grants)
Other grant funding (not including HRSA
and RCORP grant funding)
Fees
Applying for an 11-15 waiver
Changing Medicaid formularies
Increasing insurance reimbursement (both
costs covered and new insurance payers)

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OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures
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Becoming a line item in a state or local
budget
Creating certification/licensing programs to
facilitate workforce payments (e.g., peer
recovery specialists)
Other: please describe (text box)

DEMOGRAPHICS
These tables collect demographic information for all individuals who have received direct services for
SUD/OUD use disorder, within the current reporting period in the project’s rural service area. The total
number of each sub-section should equal the total number of individuals who have received direct
services within the current reporting period. Each sub-section should total to the same amount. Please
do not leave any sections blank or use N/A (not applicable) since the measures are applicable to all
RCORP grantees providing direct services. If the number for a particular category is zero (0), please put
zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero
in that section). If data are incomplete or have other limitations, please enter the data you have,
indicate the data have limitations, and explain those limitations in the comments box below.
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Measure Instructions
Please report the number of individuals
served, by ethnicity, during the current
reporting period.

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Please report the number of individuals
served, by race, during the current reporting
period.

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Please report the number of individuals
served, by age, during the current reporting
period.

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Please report the number of individuals
served, by insurance status, during the
current reporting period.

Measure
• Hispanic or Latino
• Not Hispanic or Latino
• Unknown
• Total
• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White
• More than one race
• Unknown
• Total
• 0-12
• 13-17
• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65 and over
• Total
• Self-pay
• None/Uninsured

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures
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Dual Eligible (covered by both Medicaid and
Medicare)
Medicaid/CHIP only
Medicare only
Medicare plus supplemental
TriCARE
Other third party (e.g., privately insured)
Unknown
Total

DIRECT SERVICES
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Measure Instructions
Please report the total number of individuals
who have been screened for substance use
disorder (SUD) in the current reporting
period.
Please report the total number of individuals
who screened positive for SUD, or at risk for
overuse/misuse, in the current reporting
period. If known, please specify the number
of individuals who screened positive for
specific substances. While individuals could
screen positive for multiple substances, each
subcategory should not exceed the total.

Measure
Number of individuals screened for SUD

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Please report the total number of individuals
diagnosed with substance use disorder
(SUD) in the current reporting period. If
known, please specify the number of
individuals who were diagnosed for specific
SUDs. While individuals could be diagnosed
with multiple SUDs, each subcategory
should not exceed the total.

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Total number of individuals who screened
positive for alcohol or substance use
Number of individuals who screened
positive for alcohol overuse/misuse (or at
risk for this)
Number of individuals who screened
positive for opioid overuse/misuse (or at
risk of this)
Number of individuals who screened
positive for psychostimulant
overuse/misuse (or at risk of this)
Number of individuals who screened
positive for other substance
overuse/misuse (or at risk of this) (specify)
Total number of individuals diagnosed with
an SUD
Number of individuals diagnosed with
alcohol use disorder
Number of individuals diagnosed with
opioid use disorder
Number of individuals diagnosed with
psychostimulant use disorder
Number of individuals diagnosed with other
SUD (specify)

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures
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Please report the total number of patients
diagnosed with SUD who were also screened
for clinical depression using an age
appropriate standardized tool
Please report the total number of patients
diagnosed with SUD who were tested for
HIV/AIDS
Please report the total number of patients
diagnosed with SUD who were tested for
HCV
Please report the total number of patients
diagnosed with SUD who were referred to
SUD treatment
Please report the total number of individuals
who received recovery support services in
the current reporting period.
Please report the number of patients
diagnosed with SUD who were referred to
support services.

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Please report the total number of patients
who have received MAT only or MAT with
psychosocial therapy

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Please report the total number of patients
who have received MAT (including
medication AND psychosocial therapy) for a
period of three months or more without
interruption

Patients with an SUD diagnosis who were
screened for depression
Patients with an SUD diagnosis who were
tested for HIV/AIDS
Patients with an SUD diagnosis who were
tested for HCV
Patients with an SUD diagnosis who were
referred to treatment
Number of individuals who received recovery
support services
Number of patients with a diagnosis of SUD
who were referred to support services:
• Childcare
• Employment services
• Prenatal/postpartum care services
• Recovery housing
• Transportation to treatment
• Other - specify
• Number of patients who received MAT AND
psychosocial therapy
• Number of patients who received MAT
ONLY
Number of patients who have received MAT for
three months or more without interruption

WORKFORCE
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Measure Instructions
Please report the total number of
unduplicated providers within the
Consortium who provided SUD/OUD

Measure
• Total number of unduplicated providers
(i.e., individuals) within the consortium who
provided SUD/OUD treatment services,

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures

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treatment services, mental/behavioral
health services, and/or recovery support
services in the target rural service area in
the current reporting period. Of the total
number of providers, please also report how
many were newly hired with grant funds
(e.g., their salary was paid for in full or in
part with RCORP-Implementation grant
funds) during the current reporting period.
Please report the total number of providers
(i.e., individuals) within the consortium who
have a DATA waiver to prescribe
buprenorphine-containing products for
medication-assisted treatment (MAT) within
the target rural service area
Please report the total number of providers
(i.e. individuals) within the consortium who
have prescribed medications used to treat
OUD during the current reporting period.
Please report the total number of providers
(i.e., individuals) within the consortium who
have provided SUD/OUD treatment services,
including MAT, during the current reporting
period in the target rural service area. Of
those providers, please specify how many
were medical providers, non-medical
counseling staff, peer recovery support
specialists, or other (specify).
Please report the total number of providers,
paraprofessional staff, and community
members (non-providers) who participated
in direct substance use disorder education
and training activities as a result of RCORP
funding.

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mental/behavioral health services, and/or
recovery support services in the target rural
service area
Total number of providers newly hired with
RCORP-Implementation grant funds

Total number of providers (i.e., individuals)
who have a DATA waiver (note: no FTE
required)

Total number of providers (i.e., individuals)
who have prescribed medications used to treat
OUD (note: no FTE required)

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Total Number of Providers
Number of Medical Providers
Number of Non-Medical Counseling Staff
Number of Peer Recovery Support
Specialists
Other – specify

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Mental health first aid trainings
Naloxone trainings
Opioid prescribing guidelines trainings
Stigma reduction trainings
Other - specify

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PREVALENCE---OPTIONAL SECTION (previously required)
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Measure Instructions
Please report the total number of non-fatal
overdoses from opioid poisoning in your
project’s service area.

Measure
Number of non-fatal opioid overdoses in the
project’s service area.

OMB Number: 0906-0044
Expiration Date: XX/XX/202X.

RCORP-Implementation Measures
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Please report the total number of fatal
overdoses from opioid poisoning in your
project’s service area.
Please report the total number of infants
born with Neonatal Abstinence Syndrome
(NAS)/Neonatal Opioid Withdrawal (NOW)
Syndrome-related symptoms in the project
service area.

Number of fatal opioid overdoses in the
project’s service area.
Number of NAS/NOW-related births in the
project’s service area.

Public Burden Statement: The purpose of this data collection is to provide data on each Rural Communities Opioid
Response Program initiative to enable HRSA to provide aggregate program data required by Congress under the
Government Performance and Results Act of 1993. 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 OMB control number. The OMB control number
for this project is 0906-0044 and it is valid until XX/XX/202X. Public reporting burden for this collection of information is
estimated to average 1.63 hours per response, including the time for reviewing instructions, searching existing data sources,
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 HRSA Reports Clearance Officer,
5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].