Form 2 Rural Communities Opioid Response Program-Psychostimulan

RCORP-Psychostimulant Measures

OMB Number: 0906-0044

Expiration Date: 8/31/2026.

SERVICE AREA AND CONSORTIUM

#	Measure Instructions	Measure
1	Identify the number and types of medical organizations and agencies in your consortium.	Co-occurring mental and substance abuse treatment provider Hospital - Critical Access Hospital (CAH) Hospital - Small Rural (49 beds or less, non-CAH) Hospital - Other (e.g., Sole Community, Rural Referral Center, etc.) Emergency medical services entity Federally Qualified Health Center (FQHC) FQHC Look-alike Local or state health department Mental and behavioral health organization, practice, or provider Mental health treatment provider – Community based organization Mental health treatment provider – Licensed therapist Mental health treatment provider – Psychiatrist / psychiatric services Mental health treatment provider – Other Primary care practice or provider Rural Health Clinic Ryan White HIV/AIDS clinic Substance abuse treatment provider – Methadone clinic Substance abuse treatment provider – Opioid treatment program (OTP) Substance abuse treatment provider – Other Other medical agency or organization, Type 1- Specify: Other medical agency or organization, Type 2- Specify Other medical agency or organization, Type 3- Specify
2	Identify the number and types of social service and non-medical organizations and agencies in the consortium	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 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 1- Specify Other social service and non-medical agency or organization, Type 2- Specify Other social service and non-medical agency or organization, Type 3- specify
3	Select the option that best describes your project’s service area	Single County Multiple Counties State Multiple States National
4	Identify the State(s)/Territories and county/counties included in the project service area. Select from the 'States/Territories' and ‘Counties’ drop-down and then click on the 'Add' button and repeat if needed. Territories are listed at the bottom of the drop-down. Please note that only HRSA-designated rural counties should be included in your service area.	Dropdown for States/Territories Dropdown for Counties
5	Please report the total number of people that live in the project’s rural service area.	Total population in the project’s rural service area
6	Please report the total number of consortium meetings conducted in the current reporting period in which the majority (>75%) of members participated.	Total number of consortium meetings conducted in the current reporting period
7	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.	Total number of unduplicated service delivery sites offering at least one prevention, treatment and/or recovery service
8	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.	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 Other - specify
9	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.	Total number of unduplicated service delivery sites offering at least one harm reduction service
10	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.	Naloxone access Syringe services Fentanyl test strips Safe smoking kits Sex worker services Other - specify
11	For each service listed, select whether it was newly established with or without RCORP-Psychostimulant Support funds, expanded with or without RCORP-Psychostimulant Support funds, remained the same, or did not exist in the current reporting period (dropdown).	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
12	NOTE: Sustainability measures only reported in final reporting period of the grant (Sept. 2024) Will the consortium as a unit and/or at least one key consortium activity be sustained after the RCORP grant ends?	Yes No
13	If you selected yes in previous sub-section, what will sustain? (check all that apply)	Consortium as a unit At least one key consortium activity
14	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)	Absorption of services or other means of in-kind support Reimbursement by third party payers RCORP grant funding HRSA grant funding (not including RCORP grants) 15Other grant funding (not including HRSA and RCORP grant funding) Fees Formulary funds Other: please describe (text box)

DEMOGRAPHICS

These tables collect demographic information for all individuals who have received direct services for psychostimulant 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.

#	Measure Instructions	Measure
15	Please report the number of individuals served, by ethnicity, during the current reporting period.	Hispanic or Latino Not Hispanic or Latino Unknown Total
16	Please report the number of individuals served, by race, during the current reporting period.	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one race Unknown Total
17	Please report the number of individuals served, by age, during the current reporting period.	0-12 13-17 18-24 25-34 35-44 45-54 55-64 65 and over Total
18	Please report the number of individuals served, by insurance status, during the current reporting period.	Self-pay None/Uninsured 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
19	Please report the number of individuals served, by sex, during the current reporting period.	Male Female Unknown Total
20	Please report the number of individuals served, by LGBTQI+, during the current reporting period.	LGBTQI+ Non-LGBTQI+ Unknown Total

DIRECT SERVICES

#	Measure Instructions	Measure
21	Please report the total number of individuals who have been screened for substance use disorder (SUD) in the current reporting period.	Number of individuals screened for SUD
22	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.	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)
23	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.	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)
24	Please report the total number of individuals with a positive screen and/or diagnosis of substance use disorder (SUD) who were referred to SUD treatment during the current reporting period.	Number of individuals with a positive screen and/or an SUD diagnosis who were referred to SUD treatment
25	Please report the total number of individuals who have received contingency management services in the current reporting period.	Number of individuals who received Contingency Management services for psychostimulant use disorder
26	Please report the total number of individuals who received an SUD treatment service other than contingency management in the current reporting period.	Number of individuals who received an SUD treatment service other than contingency management
27	Please report the total number of individuals who received recovery support services in the current reporting period.	Number of individuals who received recovery support services
28	Please report the total number of individuals who have been screened for a mental health disorder in the current reporting period.	Total number of individuals screened for a mental health disorder
29	Please report the total number of individuals who screened positive and/or had a mental health diagnosis who were referred to mental health treatment during the current reporting period.	Number of individuals who screened positive or had a mental health diagnosis who were referred to mental health treatment
30	Report the total number of individuals diagnosed with a mental health disorder in the current reporting period. If known, please specify the number of individuals who were diagnosed for a specific mental health disorder within the following subcategories. Each subcategory should not exceed the total.	Total number of individuals diagnosed with a mental health disorder Number of individuals diagnosed with an anxiety disorder Number of individuals diagnosed with a mood disorder (e.g., major depressive disorder) Number of individuals diagnosed with a trauma- and stressor-related disorder Number of individuals diagnosed with an eating disorder Number of individuals diagnosed with a psychotic disorder Number of individuals diagnosed with a personality disorder Number of individuals diagnosed with other mental health disorder (specify)
31	Please report the total number of individuals who were tested for HIV during the current reporting period.	Number of individuals who were tested for HIV
32	Please report the total number of individuals who were tested for HCV during the current reporting period.	Number of individuals who were tested for HCV
33	Report the total number of individuals with a SUD and/or mental health diagnosis who were referred to support services during the current reporting period, by type of service. While individuals could be referred to multiple services, each subcategory should not exceed the total.	Total number of individuals with an SUD and/or mental health diagnosis who were referred to support services Number of individuals referred to childcare services Number of individuals referred to employment services Number of individuals referred to recovery housing services Number of individuals referred to prenatal/postpartum care services Number of individuals referred to transportation to treatment Number of individuals referred to trauma-informed services Other – specify

WORKFORCE

#	Measure Instructions	Measure
34	Please report the total number of unduplicated providers within the consortium who provided SUD/OUD 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 grant funds) during the current reporting period.	Total number of unduplicated providers (i.e., individuals) Total number of providers newly hired with RCORP-Psychostimulant grant funds
35	Please report the total number of providers (i.e., individuals) within the consortium who have a Drug Addiction Treatment Act 2000 (DATA) Waiver to prescribe buprenorphine-containing products for medication-assisted treatment (MAT) within the target rural service area	Total number of providers (i.e. individuals) who have a Drug Addiction Treatment Act 2000 (DATA) Waiver
36	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.	Total number of providers (i.e. individuals) who have prescribed medications used to treat OUD
37	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).	Total Number of Providers Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify
38	Please report the total number of providers (i.e. individuals) within the consortium who have provided SUD/OUD treatment services other than 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).	Total Number of Providers Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify
39	Please report the total number of providers (i.e., individuals) within the consortium who have provided recovery support services during the current reporting period in the target rural service area.	Total Number of Providers Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify
40	Please report the total number of providers (i.e., individuals) who have provided mental/behavioral health treatment services 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).	Total Number of Providers Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify
41	Report the total number of SUD and/or mental health disorder trainings conducted in the current reporting period as a result of RCORP funding in the target rural service area. For each topic area, please provide the number of trainings in each category.	Number of ACES trainings Number of contingency management trainings Number of behavioral therapy trainings Number of mental health first aid trainings Number of Naloxone trainings Number of Opioid prescribing guidelines trainings Number of school-based evidence-based practices trainings Number of stigma reduction trainings Number of trauma-informed evidence-based practices trainings Other - specify

PREVALENCE

#	Measure Instructions	Measure
42	Using the following scale, please indicate the degree to which non-fatal overdoses have changed within the current reporting period.	Significantly increased Increased Decreased Significantly Decreased No change
43	Using the following scale, please indicate the degree to which fatal overdoses have changed within the current reporting period.	Significantly increased Increased Decreased Significantly Decreased No change

OTHER

#	Measure Instructions	Measure
44	Among the drug types listed, please rank in order the top three drug types that currently pose the greatest concern to the health and well-being of your service area	Alcohol Methamphetamine Fentanyl and Fentanyl Analogs (i.e. synthetic opioids) Heroin Prescription opioids Marijuana Benzodiazepines
45	Among the drug types listed, please rank in order the top three drug types that your service area has the least capacity to treat.	Alcohol Methamphetamine Fentanyl and Fentanyl Analogs (i.e. synthetic opioids) Heroin Prescription opioids Marijuana Benzodiazepines
46	Among the problem areas listed, please rank in order the top three problem areas that currently pose the greatest concern to the health and well-being of your HRSA-designated rural service area.	Drug-related bacterial infections (e.g., infectious endocarditis) Drug-related HIV infection Drug-related viral Hepatitis (A, B, C) Fatal and non-fatal overdoses (all drugs) Neonatal Abstinence Syndrome Opioid poisonings among children aged 1-4 years
47	Among the problem areas listed, please rank in order the top three problem areas that your HRSA-designated rural service area has the least capacity to address.	Drug-related bacterial infections (e.g., infectious endocarditis) Drug-related HIV infection Drug-related viral Hepatitis (A, B, C) Fatal and non-fatal overdoses (all drugs) Neonatal Abstinence Syndrome Opioid poisonings among children aged 1-4 years
48	Among the populations listed, please rank in order the top three population that are currently most at risk for a substance use disorder within your HRSA-designated rural service area.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
49	Among the populations listed, please rank in order the top five populations at risk for an SUD that your HRSA-designated rural service area has the least capacity to address.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
50	Please rank the top five populations that are most vulnerable to health disparities among people with and without SUD within your service area.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
51	Please rank the top five populations that are vulnerable to health disparities among people with and without SUD in your service area that you have had challenges in engaging or providing services.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
52	Among the social determinants of health listed, please rank in order the top five areas that are pose the greatest threat to the health and well-being of your HRSA-designated rural service area.	Child maltreatment Community violence Criminality Developmental Disabilities Domestic violence Juvenile delinquency Homelessness Poverty Suicide Unemployment Other (specify)
53	Among the social determinants of health listed, please rank in order the top five areas that your HRSA-designated rural service area has the least capacity to address.	Child maltreatment Community violence Criminality Developmental Disabilities Domestic violence Juvenile delinquency Homelessness Poverty Suicide Unemployment Other (specify)
54	Please rate the degree to which the following pose challenges to your service system and those you are actively trying to address.	Care coordination between mental health, substance use, and other healthcare providers Infrastructure for data sharing Partnerships between local, state and federal funders and licensing bodies Affordability Third party reimbursement Stigma - Among community members Stigma - Among service providers Service capacity - Mental health services Service capacity – recovery services Service capacity - SUD services Service capacity - Services treating co-occurring mental health and SUDs Workforce capacity - Mental health providers Workforce capacity - SUD providers Workforce capacity - Providers treating co-occurring mental health and substance use disorders Wrap-around services for individuals with co-occurring mental health and substance use disorders Other (please specify) None of the above
55	Is your consortium currently utilizing telehealth/telemedicine as part of your RCORP project?	Yes No
56	If yes, please provide a 2-3 sentence overview of how your consortium is leveraging telehealth/telemedicine to implement your project
57	If applicable, select the types of services your consortium is currently using telehealth/telemedicine for (select all that apply)	Case management Group therapy Individual counseling Intake and assessments Prescribing MAT Recovery services, including meetings with peer support workers Other (specify)
58	If applicable, select the telehealth platform types your consortium is currently using (select all that apply)	Audio-only telehealth Mobile/app-based health services (e.g., My Strength, text messages, text alerts) Store-and-forward communication (e.g., Health Lens, online patient portal) Video conferencing (e.g., Zoom, Doxy.me) Other (specify)
59	Select the challenges your consortium has experienced in trying to implement telehealth (select all that apply)	Billing and reimbursement challenges Concerns about sustainability of reimbursement Discomfort with technology Expensive equipment Internet/cell phone minute costs for staff Lack of cellular connections Lack of reliable broadband access Privacy concerns/HIPAA compliance concerns Staff discomfort with telehealth services (e.g., too impersonal) Other (specify) None of the above
60	Select the challenges patients/clients served by your consortium have experienced with telehealth (select all that apply)	Discomfort with technology Discomfort with telehealth services (e.g., too impersonal) Expensive equipment needed to access telehealth Internet/cell phone minute costs Lack of internet or cellular connections Privacy concerns Other (specify) None of the above
61	What MAT medications (drug name and form) are currently being prescribed/distributed by at least one partner in your HRSA-designated rural service area? (select all that apply)	Buprenorphine, sublingual tablets (e.g., Subutex) Buprenorphine, extended-release subcutaneous injection (e.g., Sublocade) Buprenorphine, implant for subdermal administration (e.g., Probuphine) Buprenorphine with Naloxone, sublingual film (e.g., Suboxone film, Cassipa) Buprenorphine with Naloxone, buccal film (e.g., Bunavail) Buprenorphine with Naloxone, sublingual tablets (e.g., Zubsolv) Methadone, oral tablets (e.g., Dolophine) Methadone, oral concentrate (e.g., Methadose) Naltrexone, oral tablets (e.g., ReVia, Depade) Naltrexone, extended-release injection (e.g., Vivitrol) Other (please specify) None of the above

Public Burden Statement: The purpose of this activity is to collect information on Rural Communities Opioid Response Program grantees to provide HRSA with information on grant activities funded under this program. 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 information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 U.S.C. 912). Data will remain private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average approximately 1 hour and 22 minutes 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.