Data Entry Form

OD2A: LOCAL Linkage to and Retention in Care
Data Entry Form
Metadata
1. Select the entry points for which your jurisdiction is reporting
data. (At least two entry points must be selected, one of which
must be Nonfatal overdose.)

2. Describe the population captured at each entry point for which
your jurisdiction is reporting data.
3. Please identify and describe the data sources that were used to
report data on each indicator. Descriptions should comment on
data availability, frequency of data availability, data granularity,
whether the data is identifiable, and whether data is linked to
other data sources.
4. Describe any changes or improvements in data sources since the
previous reporting period.
5. Please provide a qualitative assessment of the data coverage or
representativeness for each reported indicator for the nonfatal
overdose entry point.
6. Please provide a qualitative assessment of the data coverage or
representativeness for each reported indicator for additional entry
points.
7. Please identify other strengths and limitations of the data based
on the other quality attributes, like uniqueness, timeliness,
validity, accuracy, and consistency.
8. Who should CDC contact with questions about this data report?

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Nonfatal overdose
Other clinical
Criminal justice
Harm reduction program
Community-based program
Self-referral
Other

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_____________________________
_____________________________

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Name: _______________________
Email: _______________________

Indicators
General Information
Jurisdiction Name

____________________________

Quarter/Year

____________________________

Entry Point

o
o
o
o
o
o
o

Nonfatal overdose
Other clinical
Criminal justice
Harm reduction program
Community-based program
Self-referral
Other

Substance Type

o
o

Opioid
Stimulant

o
o

Yes
No

Demographic Characteristics
Are you reporting indicators disaggregated by
demographic characteristics?

(If “Yes,”, we strongly suggest submitting data using the Data
Import Tool)

Sex: Select.

Age Group: Select.

Race: Select.

Indicators
Number of individuals identified

Enter number.

Number of individuals engaged

Enter number.

Referred by Service Type
Service Type

Number of individuals referred

Any treatment

Enter number.

MOUD

Enter number.

Behavioral treatment

Enter number.

Harm reduction services

Enter number.

Treatment Initiation by Service Type
Service Type
Any treatment

Number of individuals who initiated
Enter number.

Ethnicity: Select.

MOUD

Enter number.

Behavioral treatment

Enter number.

Harm reduction services

Enter number.

Treatment Status 6 Months After Initiation
Retained

Completed

Lost to
follow-up

Incarcerated

Deceased

Other

Unknown

MOUD

Enter.

Enter.

Enter.

Enter.

Enter.

Enter.

Enter.

Behavioral
treatment

Enter.

Enter.

Enter.

Enter.

Enter.

Enter.

Enter.

Service Type