Supporting Doc 2

APPENDIX A

SPF SIG Authorizing Legislation

APPENDIX B

SPF SIG Community-level Instrument (Parts I and II)

Burden Statement: Public reporting burden of this collection of information is estimated to average XX hours per response.  Send all comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, Choke Cherry Road, Rockville, MD 20857.  An agency may not sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  The control number for this project is XXXX-XXXX.

Form Approved

OMB No. XXXX-XXXX

Expiration Date XX/XX/XXXX

Strategic Prevention Framework

State Incentive Grant

(SPF SIG)

Cross-Site Evaluation

Community Level Instrument

(Part I):

Community Partner Activities

May 2006

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Prevention

S

PF SIG Cross-Site Evaluation, Community-level Instrument, Part I

Information and Directions 2

State Questions 4

Record Management 7

Contact Information 7

Reporting Period 7

Community Partner Organizational Information 8

Organization Type and Funding 8

Cultural Competence Policies and Practices 11

Strategic Prevention Framework 13

Needs and Resources Assessments 14

Capacity Building 21

Organizational Resources 23

Community Awareness 24

Relationship Building 27

Sustainability 45

Strategic Plan Development 47

Intervention Implementation 53

Monitoring and Evaluation 55

Systems Factors 58

Contextual Factors 60

Closing Questions 62

Coalition Sub-Form 63

Information and Directions

This instrument is designed to collect information about the activities of the community partners for the Strategic Prevention Framework -State Incentive Grant (SPF SIG) Initiative. This information will be collected every 6 months, with a select number of questions being asked only once throughout the life of the grant.

The CLI is designed as a two-part survey. Part I collects data about the community’s progress through the strategic prevention framework. Part II collects information about the specific intervention(s) being implemented by the community. The community will complete a separate Part II form for each intervention implemented. For example, if the community is implementing both a participant-based education intervention and an environmental intervention, they will complete two Part II forms. Data collected from the survey will be used to evaluate the effectiveness of the Strategic Prevention Framework.

Completion of this survey is a requirement of accepting funding from CSAP under the SPF SIG grant initiative. However, respondents may choose not to answer a specific question and respondents may end the survey at any time. Each community partner will be assigned a unique numerical identification. This identification will be used to ensure that communities cannot be identified. In addition, no individuals will be identified in the reporting of results.

Items 1 to 11 are to be answered by the state SPF SIG reviewer. If the state is conducting the community level evaluation, questions 41 through 44 in Part II, on evaluation outcomes, will also be completed by the state. The remaining questions are to be answered by the community partner.

Make sure to read all of the directions and examples, which are provided in italics.

Directions for skipping questions are indicated where appropriate to minimize the time needed to complete the questionnaire. This web-based survey is designed to automatically take you to the appropriate question, but you should still follow the directions closely.

Throughout this instrument, words that are underlined are hyperlinked to a list of definitions. In addition, if you click here you can access SAMHSA’s prevention glossary. (Web programming note: include link to: http://preventionplatform.samhsa.gov/MacroHQ/Glossary2/dssglossary.cfm?sect_id=1&topic_id=99&CFID=261427&CFTOKEN=54631918 .)

Throughout this document, the term “you” refers to the community partner that has received SPF SIG funding from the state. This could be an organization, coalition, or other entity. If this community partner is a community coalition, the Project Director for the SPF SIG project is required to complete the instrument, with input from other coalition members as needed.

You are strongly encouraged to obtain input from others involved with the SPF SIG funded project. Each section of the instrument includes a list of individuals whom you may want to consider asking to assist you in this data collection process. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, such as the project coordinator, evaluator, intervention delivery staff, and others, as appropriate.

Prior to completing the survey, you may find it helpful to gather the following materials to help answer questions:

• Budgets

• Results of needs/resources assessments

• Strategic plans

• Meeting minutes

• Memorandums of understanding

• Intervention implementation materials (curricula, programs, etc.)

• Evaluation findings/reports

• Policies regarding cultural competence

As you enter your data, you will be able to save your work and come back to it at another time. You may also write your responses to the narrative response questions in advance using a word processor and copy and paste them into the web-based survey.

If you need assistance in completing this instrument, contact Shelly Kowalczyk at (301) 587-1600 or via e-mail at skowalczyk@mayatech.com

SPF SIG Cross-Site Evaluation, Community Level Instrument, Part I

State Questions

The following questions will be completed by the state level reviewer. (Web programming note: The state level reviewer will be designated in the log-in function.)

To be answered by the state SPF SIG reviewer, for the state as a whole:

1. What is the state procedure for monitoring the SPF process at the community level? (Select all that apply.)

Communities must submit formal results of a needs and resources assessment.

Communities must submit formal strategic plans.

Communities must obtain approval of their strategic plans.

The state monitors the communities’ intervention selection to ensure that interventions match the target outcomes and causal factors identified.

The state conducts community-level evaluation.

The community conducts its own evaluation and reports back to the state.

Don’t know

Other (Describe.)_________________________________________________________

2. Did your state select a statewide substance abuse problem that all funded communities are targeting? (Select yes or no.)

Yes

No (If no, proceed to question 4.)

3. Describe the statewide substance abuse problem the communities are focusing on:

4. Is your state allowing the communities to proceed with the Strategic Prevention Framework without conducting a community needs and resources assessment? (Select yes or no.)

 Yes

 No

To be answered by the state SPF-SIG reviewer for the state as a whole, every reporting period:

5. Did you conduct an assessment of the training and technical assistance needs of the prevention workforce within your state, during this reporting period? This assessment could be a formal assessment that involves interviews with key stakeholders and formal surveys or it could be an informal assessment of the workforce needs of the community. (Web programming note: definition link). (Select yes or no.)

Yes

No

6. Were there opportunities for skills development and/or continuing education for the prevention workforce (Web programming note: definition link) within your state, during this reporting period? We are interested in opportunities funded by SPF SIG and other funding sources. Examples of workforce training opportunities might include continuing education credits offered for a seminar or workshop, or mandatory training on a new process or procedure being used in your state for substance abuse prevention efforts. (Select one response.)

Yes

No

Don’t know

To be answered by the state SPF SIG reviewer for the funded community partner:

7. Indicate the month and year this community partner began receiving SPF SIG funds:

MM/YYYY ____/______

8. Indicate the month and year SPF SIG funding for this community partner is scheduled to end for the overall project.

MM/YYYY ____/______

9. Select the description of “community” being used by this community partner. Examples of a specific target population within a defined geographic area include high school students attending public schools, men having sex with men (MSMs) in a specific neighborhood, or the pregnant women of a specific metropolitan area. If your description of “community” includes targets such as these, select “a specific target population within a defined geographic area.” (Select all that apply.)

A defined geographic area, such as a neighborhood, city, or county

A specific statewide target population, such as high school students

A specific target population within a defined geographic area

Don’t know yet (Web programming note: If this option is selected, respondent should not be able to select others.)

Other (Describe.)_________________________________________________________

To be answered by the state SPF SIG reviewer for the funded community partner, every reporting period:

10. Are there specific workforce issues within this SPF SIG community that we should be aware of? Examples of community-specific workforce issues include a community college or hospital discontinuing a training or certification program. (Select one response.)

Yes

No (If no, proceed to question 12.)

Don’t know (If marked, proceed to question 12.)

11. Describe the community-level workforce issues.

Record Management

(Web programming note: This section of the instrument will be designed as a “User Identification Tab” on the Web site. Respondents will only need to complete this section once, unless they have changes in their contact information to report.)

Contact Information

12. Name: ___________________________________________

13. Title: ____________________________________________

14. Name of organization: ___________________

15. Telephone number: _____________________________

16. Email address: ________________________________

17. Instrument submission date: ______________(Web programming note: this field will autofill based on the date the state provides approval of the instrument and submits it.)

18. State: ____________________________________________________________________

19. Create a Community Partner Grantee ID_________________________________________

Reporting Period

20. Mark the timeframe for which you are reporting.

October 1, 2004–March 31, 2005

April 1, 2005–September 30, 2005

October 1, 2005–March 31, 2006

April 1 2006–September 30, 2006

October 1, 2006–March 31, 2007

April 1, 2007–September 30, 2007

October 1, 2007–March 31, 2008

April 1, 2008–September 30, 2008

October 1, 2008–March 31, 2009

April 1, 2009–September 30, 2009

Community Partner Organizational Information

This section asks you to describe your organization. Information about other funding sources, staff hired to help implement these intervention(s) (Web programming note: definition link), and information about policies that have been developed that address cultural competence (Web programming note: definition link) also is collected in this section.

People you may want to include in responding to this section:

• Project Director

• Project Coordinator

• Person with responsibility or knowledge of financial issues

Organization Type and Funding

21. As a community partner, what type of organization would you say you are? (Select one response that best describes your organization.)

 We are a community coalition (Web programming note: definition link) and do not have any other organization type. (If selected, proceed to question 23 and complete the coalition sub-form.)

 Non youth-focused, local grassroots or community-based service and/or advocacy organization (e.g., substance abuse prevention organizations, HIV prevention organizations, YMCAs)

 Faith-based organization

 Youth-focused local grassroots or community-based service and/or advocacy organization (e.g., local chapter of Students Against Destructive Decisions, local youth councils, Boy Scouts/Girl Scouts, Big Brothers/Big Sisters)

 Other non-profit organization, not listed above

 School district

 Law enforcement organization

 College/university

 Government agency

 Local healthcare facility, treatment or prevention provider/facility (e.g., local hospital, community mental health center, local substance abuse prevention agency)

 Other (Describe.)________________________________________________

22. Are you partnering with a community coalition (Web programming note: definition link)? By partnering, we mean a formal relationship that is documented with a Memorandum of Understanding or similar agreement and/or to whom SPF SIG funding is provided. (Select yes or no.)

Yes

No (If no, proceed to question 25.)

23. What month and year was the coalition (Web programming note: definition link) established? (Provide MM/YYYY or select don’t know)

MM/YYYY ____/______

Don’t know

24. Indicate the role of the coalition (Web programming note: definition link) in changing community capacity, knowledge, norms and behaviors related to substance abuse prevention and program implementation. (Select all that apply.)

 Collect and organize data (Web programming note: definition link)

 Conduct needs assessments (Web programming note: definition link)

 Train community members in substance abuse prevention

 Leverage funds from sources other than the SPF SIG

 Plan and/or implement interventions (Web programming note: definition link)

 Ensure SPF SIG funded intervention(s) (Web programming note: definition link) address issues related to cultural competence (Web programming note: definition link)

 Plan and/or implement process or outcome evaluations of interventions

 Set substance abuse policy at the organizational, local, or state level

 Educate others about needed changes in substance abuse policy at the organizational, local, or state level

 Other (Describe.)______________________________________

 Don’t know (Web programming note: If this option is selected, respondent should not be able to select others.)

25. Do you currently receive alcohol, tobacco or other drug prevention funding from sources other than the SPF SIG Initiative? This question pertains to the funded organization as a whole, not just the specific SPF SIG intervention. (Select one response.)

 Yes

 No (If no, proceed to question 27.)

 Don’t know (If marked, proceed to question 27.)

26. What other types of funding do you currently receive? (Select all that apply.)

 State funds

 County or municipal funds

 Foundation funds

 Private contributions from individuals

 Corporate contributions

 Weed and Seed

 Federal Substance Abuse Prevention and Treatment Block Grant funds

 Drug Free Communities funds

 Safe and Drug Free Schools funds

 SIG funds (this is funding that came from the first round of State Incentive Grants, and does not include current SPF SIG funding)

 SIG planning funds

 SIG enhancement funds

 Community Anti-Drug Coalitions of America (CADCA)

 Department of Justice, Office of Juvenile Justice and Delinquency Prevention funds

 Medicaid, as provided by a managed care organization

 Other Federal funds (Describe.) ____________________________________

 Other (Describe.) _______________________________________________

 Don’t know (Web programming note: If this option is selected, respondent should not be able to select others.)

Cultural Competence Policies and Practices

These questions collect information on how you, as the funded community partner, address cultural competence in your organization, coalition, or agency.

27. Indicate the areas in which you, as the community partner, have formal, written policies and practices in place to address cultural competence (Web programming note: definition link). This section may not apply to coalitions or other organization types that do not have formal policies. For purposes of this question, we are only interested in those areas in which you have formal, written policies. There are many reasons an organization may not have formal, written policies in place to address cultural competence and your honest answer is valuable to the cross-site evaluation. If this question does not apply to your situation because as a coalition you do not have formal written policies, indicate "not applicable" in the response options below. (Select all that apply.)

 Organizational administration (e.g., purchasing, contracting)

 Board representation (e.g., board recruitment, board leadership)

 Training and staff development

 Language and internal and external communication (e.g., availability of interpreters, documents avoid derogatory language)

 Service approach (Web programming note: definition link)

 Evaluation design (Web programming note: definition link)

 Data collection (qualitative and quantitative)

 Other (Describe.) ­­­­­­­­­­­­­­­_______________________________________________________

 We are aware that cultural competence is an issue but we have not developed formal, written policies yet or these policies are currently being developed. (If marked, proceed to question 30.)

 Don’t know (If marked, proceed to question 30.)(Web programming note: If this option is selected, respondent should not be able to select others.)

 Not applicable (If not applicable, proceed to question 30.)(Web programming note: If this option is selected, respondent should not be able to select others.)

28. How is compliance with cultural competence (Web programming note: definition link) policies and/or practices monitored within your organization, as the community partner? (Select one response.)

 Compliance is not monitored at all

 Compliance is monitored once a year or less frequently by a director, executive, or administrator (Web programming note: definition link)

 Compliance is monitored twice a year or more often by a director, executive, or administrator (Web programming note: definition link)

 Compliance is monitored once a year or less frequently by someone other than a director, executive, or administrator (Web programming note: definition link)

 Compliance is monitored twice a year or more often by someone other than a director, executive, or administrator (Web programming note: definition link

 Don’t know if compliance is monitored or don’t know how compliance is monitored

29. If contract agencies (Web programming note: definition link) are used, are they held to the same standards with regard to cultural competence (Web programming note: definition link)? (Select one response.)

Yes

No

Don’t know

Not applicable

30. Did you receive SPF SIG funded guidance, training or technical assistance with regard to cultural competence (Web programming note: definition link) during this reporting period? The guidance could have been provided by the state or some other entity that was funded through SPF SIG funds. Examples might include training on developing culturally competent hiring practices or adapting interventions to address cultural appropriateness. Do not include training that you are going to receive in the future. You will be able to report this in future reporting periods. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 32.)

31. How likely is it that you will use what you learned during the guidance, training or technical assistance on cultural competence in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

Strategic Prevention Framework

Each component of the Strategic Prevention Framework (needs assessment, capacity building, strategic plan development, intervention implementation, and evaluation) is addressed in this section. You will have the opportunity to describe your activities within each of the five components of the framework.

People you may want to include in responding to this section:

• Project Director

• Project Coordinator

• Intervention delivery staff

• Evaluator

For questions 32 and 33 below, indicate which of the five steps of the Strategic Prevention Framework you worked on during this reporting period and indicate the approximate percentage of time you spent on this component during this reporting period. If you are responding as a community coalition, estimate the amount of time members of the coalition, collectively, spent on a particular component of the Strategic Prevention Framework (SPF). Make sure the percentage of time spent on each component adds up to 100%. For example, if all of your time this reporting period was spent conducting the needs assessment, you would respond that 100% of your time was for needs assessment. If you divided your time equally between all five components, you would respond that you spent 20% of your time on each component. We understand that you probably spent some amount of time on administrative tasks that are not technically part of one of the SPF components; however we are not capturing that information here. (Select all that apply and indicate a percentage. Total should equal 100%.)

SPF Component	Percentage of Time Spent This Reporting Period
a.Needs assessments (Web programming note: definition link)	a. _____%
b. Capacity building (Web programming note: definition link)	b. _____%
c. Strategic plan development (Web programming note: definition link)	c. _____%
d. Intervention implementation (Web programming note: definition link)	d. _____%
e. Monitoring and evaluation (Web programming note: definition link)	e. _____%
	Total 100%

Needs and Resources Assessments

This section collects information on organizational and community needs and resources assessments (Web programming note: definition link) you conducted during this reporting period. You are asked whether or not the needs and resources of your organization and the community have been analyzed. It also provides you with an opportunity to describe the needs and resources that have been identified. Finally, the section asks about the consumption patterns, consequences, and populations you plan to target, based on the needs assessments.

People you may want to include in responding to this section:

• Project Director

• Project Coordinator

• SEOW Liaison

• Data Coordinator

34. Have you completed an organizational needs and resources assessment (Web programming note: definition link) during this reporting period? Only answer “yes” if your assessment was completed during this reporting period. If the assessment was still being conducted at the end of the reporting period, select “no.” You will be able to answer “yes” and provide more detail in the next reporting period. Organizational needs assessments examine needs internally and include assessments of leadership, human resources, technical resources (e.g., telephones, computers, or appropriate software), infrastructure (e.g., facility, staff offices, conference rooms), funding sources, etc. (Select yes or no.)

Yes

No (If no, proceed to question 37.)

35. Indicate the types of organizational needs and resources you assessed. This question is asking about the areas you considered or examined during this reporting period to determine the specific needs and resources you should be aware of. The next question asks you to specifically describe the needs and resources that were identified. (Select all that apply)

Mission/vision

Leadership ability

Cultural competence

Human resources

Technical resources

Infrastructure

Funding sources

Organizational experience

Up-to-date knowledge of substance abuse prevention

Other (Describe.) ________________________________________________________

36. For all items marked in question 35 (above), describe the specific organizational needs and resources that were identified. For example, “Technical resources - our organization identified a priority need for a computer dedicated to data collection and analysis.” (Provide a concise written description in the space available.)

37. Have you completed a community needs and resources assessment (Web programming note: definition link) during this reporting period? A community needs and resources assessment examines needs external to the organization, coalition or agency and includes community readiness (Web programming note: definition link), rates of substance use, prevention resources (e.g., call centers and trained counselors), partnerships, community prevention experience, and other monetary and non-monetary resources. (Select yes or no.)

Yes

No (If no, proceed to question 63.)

38. Indicate the types of community needs and resources that were assessed. (Select all that apply.)

 Data on populations not typically included in assessments (e.g., homeless, undocumented workers)

 Prevention resources (e.g., call centers and trained counselors)

 Cultural competence (Web programming note: definition link)

 Partnerships within the community

 Substance use rates of the potential target population

 Substance use consequences in potential target populations, (e.g., alcohol-related mortality)

 Factors that might cause, lead to, or promote substance use

 Experience within the community of working with the potential target population (e.g., previous encounters with the target population perhaps in serving members with prevention services or in conducting outreach to this population).

 Community readiness (Web programming note: definition link) (If selected, you must complete question 40 below.)

 Workforce (Web programming note: definition link) training issues within the community (e.g., not enough slots in a community-college training program)

 Other (Describe.) _______________________________________________________

39. Describe the community needs and resources identified through the assessment. (Provide a written description in the space available.)

(Web programming note: some states would like the opportunity to complete this question for the communities, based on information they may have submitted in their progress reports to the state.)

Web planning note: If community readiness is selected in question 39, these questions must be completed.)

40. If you indicated in question 38 that you assessed community readiness (Web programming note: definition link), did you use a community readiness measure that has been tested and/or published? An example of a tested or published community readiness measure would include the Tri-Ethnic Center’s Community Readiness Survey and the Nine Stages of Community Readiness. (Select one response.)

Yes

No (If no, proceed to question 43.)

Don’t know (If marked, proceed to question 43.)

41. If yes, what measure was used? (Provide a concise written description in the space available.)

42. What were the results of the community readiness (Web programming note: definition link) assessment? (Provide a concise written description in the space available.)

For questions 43 through 54 indicate below the types of data you used in conducting your needs and resources assessment and indicate if the data were provided to you by the State Epidemiology and Outcomes Workgroup (SEOW) (Web programming note: definition link). This would also include data that the SEOW in your state showed you how to access or use. (Select all that apply.)

	a. Student school survey data	b. Provided by SEOW
	a. School achievement data	b. Provided by SEOW
	a. Community surveys	b. Provided by SEOW
	a. Public health statistics (e.g., mortality rates due to drug overdose)	b. Provided by SEOW
	a. Census data	b. Provided by SEOW
	a. Interviews and/or focus groups	b. Provided by SEOW
	a. Public meetings or forums	b. Provided by SEOW
	a. Law enforcement data (e.g., drug arrests or drug trafficking)	b. Provided by SEOW
	a. Department of Justice data (e.g., outcomes of criminal cases)	b. Provided by SEOW
	a. Public safety data (e.g., number of automobile accidents caused by drinking and driving)	b. Provided by SEOW
	a. Social norms data	b. Provided by SEOW
	a. Other (Describe.)_________________	b. Provided by SEOW

55. Based on the needs and resources assessments described above, have you identified consumption patterns (Web programming note: definition link) that you are going to target for substance abuse prevention? (Select one response.)

Yes

No (If no, proceed to question 58.)

 

56. Indicate the consumption patterns you are targeting: (Select all that apply.)

 Underage use of alcohol

Any use of alcohol

 Heavy use of alcohol, defined as consuming five or more drinks on five or more occasions in the past 30 days

 Binge drinking, defined as consuming five or more drinks in a row at one sitting for males and four or more in a row for females

 Any use of tobacco under age 18

 Any use of tobacco 18 years of age or older

 Any use of illegal drugs (If selected, complete question 57.) (Web programming note: If this is not selected, automatically skip question 57.)

 Other consumption pattern (Describe.)_______________________________________

57. If you indicated in question 56 that you are targeting the use of illegal drugs, indicate which drugs you are targeting: (Select all that apply.)

All illegal drugs

Marijuana

Ecstasy

Cocaine

Crack cocaine

Methamphetamine/Crystal meth

Other substances (Describe.) ______________________________________________

58. Based on the needs and resources assessments described above, have you identified consequences (Web programming note: definition link) of substance use that you are targeting? (Select one response.)

Yes

No (If no, proceed to question 60.)

 

59. Indicate the consequences you are targeting: (Select all that apply).

Motor vehicle crashes

Crime

Dependence or abuse

Alcohol-related mortality

Tobacco-related mortality

Drug-related mortality

Other consequences (Describe.) ____________________________________________

 

60. Based on the needs and resources assessments described above, have you identified specific populations that you will be targeting for SPF SIG funded substance abuse prevention? Substance abuse prevention includes all substances, such as alcohol tobacco, marijuana, methamphetamine, and cocaine. (Select one response.)

Yes

No (If no, proceed to question 63.)

 

61. Indicate the populations you will be targeting for substance abuse prevention. For this question, we would like to know if you have very specific groups of people at whom your interventions will be aimed. For example, if you are delivering an intervention to all middle schools in an area, then you would only select ”middle school students.” In this example, you would not have to select all the possible race/ethnicity categories that might be enrolled in the schools. If, however, you are delivering an intervention specifically designed to target pregnant Latinas, then you would select Hispanic and pregnant women. (These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.).

All races/ethnicities

Specific races/ethnicities (Select all that apply.)

African American

American Indian/Alaska Native

Asian/Pacific Islander

White

Hispanic

Elementary school students

Middle school students

High school students

College students

Under 18

Under 21

Young adults age 18-25

Construction workers

Pregnant women

Gay/Lesbian/Bisexual/Transgender/Men who have sex with men

Other target population (Describe.) _________________________________________

 

62. If you are targeting specific consumption patterns or consequences with specific target populations, use the space below to describe those connections. For example, if you indicated that you are targeting any underage tobacco use and binge drinking, and you indicated that you are targeting high school students and college students, clarify if the tobacco use is targeted to high school students and the binge drinking is targeted to both groups. It is important that you report this information for all connections because this information will be used by the cross-site evaluation team and your state evaluators as one way of determining if your selected interventions are appropriate for your targeted consumption patterns, consequences, and target populations.

Consumption Pattern or Consequence Target Population

63. Did you receive SPF SIG funded guidance, training or technical assistance with regard to conducting a needs and resources assessment (Web programming note: definition link) during this reporting period? Do not include training that you are going to receive in the future. You will be able to report this in future reporting period. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 65.)

64. How likely is it that you will use what you learned during the guidance, training or technical assistance on needs and resources assessment (Web programming note: definition link) in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

65. If your project experienced any challenges with conducting needs and resources assessments (Web programming note: definition link) (including coalition needs and resources) during this reporting period, please describe them here. Examples might include difficulty scheduling time with key individuals to determine need, challenges accessing data, or difficulty finding the resources (time and money) to conduct the needs assessment. (Provide a concise written description in the space available.)

66. If your project experienced any specific successes with conducting needs and resource assessments (Web programming note: definition link) (including coalition needs and resources) during this reporting period, please describe them here. Examples might include identifying appropriate data or being able to contact key individuals for their input into the assessment. (Provide a concise written description in the space available.)

Capacity Building

In this section, we ask you about your activities related to capacity building. “Capacity building” refers to activities conducted to improve the ability of an organization or community to deliver substance abuse prevention services, such as improving organizational resources (Web programming note: definition link); improving awareness about substance abuse problems; building new relationships or strengthening existing relationships among coalitions (Web programming note: definition link), groups, and organizations involved in substance abuse prevention; and working to ensure intervention activities and outcomes continue after SPF SIG funding ends. Because capacity building relies on having appropriate staff to conduct these activities, we start by asking you to describe any SPF SIG staff vacancies you have had during this reporting period.

People you may want to include in responding to this section:

• Project Director

• Project Coordinator

• Human Resources

• Staff responsible for renting space, purchasing equipment, etc.

• Intervention delivery staff

• Coalition representatives

• Evaluator

For questions 67 through 68 below, indicate if any of the following staff (any person working on SPF SIG funded activities, including volunteers) positions within your organization, agency, or coalition, have been vacant during this reporting period. If any positions have been vacant, indicate the length of time they have not been filled. If a staff member is functioning in more than one position, please indicate any and all positions with vacancies. (Web programming note: These will be rows with check boxes in the web version of the instrument.)

Staff Position	Has this position been vacant at all during this reporting period?	If the position was vacant, indicate how many weeks during this reporting period it was vacant.
Leader/director/manager	Yes No NA
Coordinator	Yes No NA
Evaluator	Yes No NA
Curriculum/Intervention Developer	Yes No NA
Curriculum/Intervention Facilitator	Yes No NA
Curriculum/Intervention Aide	Yes No NA
Volunteers/Interns (non-paid positions)	Yes No NA
Other 1_________	Yes No NA
Other 2 _________	Yes No NA
Other 3 __________	Yes No NA

69. Did you work on capacity building (Web programming note: definition link) activities during this reporting period? Examples of areas in which activities could be conducted to build capacity include: organizational resources (Web programming note: definition link), community awareness, relationship building, and ensuring that intervention activities and outcomes continue after SPF SIG funding ends. (Select yes or no.)

Yes

No (If no, proceed to question 71.)

Organizational Resources

This section collects information on the activities you conducted to improve organizational and/or coalition resources such as writing mission or vision statements, identifying goals and activities, hiring and training staff, identifying leaders, obtaining physical space for the intervention, etc. It also asks about guidance, training, and assistance you may have received.

70. Indicate the activities you conducted during this reporting period to improve organizational and/or coalition resources (Web programming note: definition link). (Select all that apply.)

 We did not conduct organizational/coalition capacity building activities during this reporting period.

 Wrote, reviewed or rewrote organizational or coalition mission/vision

 Identified key organizational or coalition activities and goals

 Hired staff

 Trained staff

 Identified coalition leader(s)

 Improved cultural competence (Web programming note: definition link)

 Identified or secured physical space

 Coordinated or improved technical resources

 Coordinated data collection and/or management information systems (MIS) (Web programming note: definition link) plans

 Other: (Describe.) ______________________________________________________

71. Did you receive SPF SIG funded guidance, training or technical assistance with regard to staff, task force, and/or coalition member training during this reporting period? Do not include training that you are going to receive in the future. You will be able to report this in future reporting periods. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 73.)

72. How likely is it that you will use what you learned during the guidance, training, or technical assistance on staff, task force, and/or coalition member training in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

73. If your project experienced any challenges with improving organizational resources (Web programming note: definition link) (including coalition resources) during this reporting period, please describe them here. Examples might include challenges in locating space or obtaining equipment for the project, not being able to access SPF SIG funds in a timely manner, or not being able to agree on an organizational mission/vision. (Provide a concise written description in the space available.)

74. If your project experienced any specific successes with improving organizational resources (Web programming note: definition link) (including coalition resources) during this reporting period, please describe them here. Examples might include hosting an effective training for staff, completing a rewrite of an organizational mission/vision statement or hiring key individuals for the project. (Provide a concise written description in the space available.)

Community Awareness

This section collects information about your efforts in raising awareness of substance abuse problems in the community, the types of substance abuse problems/issues for which you are raising awareness, the community members/groups you have targeted for awareness efforts, and activities you are conducting to raise awareness.

75. Did you work to raise awareness (Web programming note: definition link) in the community of substance use or abuse problems during this reporting period? Awareness raising activities are considered those activities where your primary purpose is to draw attention to a substance abuse problem (underage drinking, methamphetamine use, etc.) or to your prevention efforts. These activities are not intended to recruit participants or volunteers, although that may happen. (Select yes or no.)

Yes

No (If no, proceed to question 81.)

76. Indicate the issues you are attempting to raise awareness (Web programming note: definition link) of in the community. (Select all that apply.)

 Substance use rates or trends

 Consequences (Web programming note: definition link) related to substance use, such as crashes or arrests for drunk driving

 Intervening variables (Web programming note: definition link) associated with substance use and consequences

 Coordination among agencies

 Funding for substance abuse prevention

 Other (Describe.)________________________________________________________

77. Indicate which community members and/or groups you are focusing your awareness (Web programming note: definition link) raising efforts on. (Select all that apply.)

 The general public

 Youth

 Parents/family/caregiver groups

 Business community

 Media (e.g., radio and television stations, newspapers and magazines)

 School(s)/school districts

 Youth serving organization(s) other than schools (e.g., Big Brothers/Big Sisters, Boy Scouts/Girl Scouts)

 Law enforcement agency/agencies

 Local or state courts

 Department of Justice

 State and/or local jails and prisons

 Faith-based organization(s) (e.g., churches or charitable organizations with religious affiliations such as Catholic Charities)

 Civic or volunteer organization(s) (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)

 Healthcare professionals

 State, local, village or tribal government agencies

 Other (Describe.)_______________________________________________________

 Don’t know

78. Indicate the activities that are being conducted to raise awareness (Web programming note: definition link) of the issue(s) marked in question 76 among the group(s) marked in question 77. (Select all that apply.)

 Media activities such as television, radio, or newspaper advertisements or public service announcements

 Internet activities such as listservs, web sites, or mass e-mails to targeted populations

 Direct mailings

 Face-to-face outreach such as health fairs, classroom visits, other community events, etc.

 Other: (Describe.) _______________________________________________________

79. If your project experienced any challenges with raising community awareness (Web programming note: definition link) during this reporting period, please describe them here. Examples might include challenges meeting with the community or getting their involvement. (Provide a concise written description in the space available.)

80. If your project experienced any specific successes with raising community awareness (Web programming note: definition link) during this reporting period, please describe them here. Examples might include hosting a successful community awareness event, or launching an awareness campaign. (Provide a concise written description in the space available.)

Relationship Building

This section collects information on how you identified potential partners to join your coalition or to support substance use and/or abuse prevention efforts in the community and how these partners are involved in the prevention intervention activities.

81. Have you identified key stakeholders (Web programming note: definition link), partners and partner organizations to participate in your SPF SIG intervention activities? (Select yes or no.)

Yes

No (If no, proceed to question 150.)

82. Think about your partners and stakeholders involved in intervention activities. Have you identified any stakeholders or partners who should be involved, but are not? (Select yes or no.)

Yes

No (If no, proceed to question 84.)

83. Describe what you are doing to bring these stakeholders and partners to the table:

The next set of questions asks you to indicate the types of groups/organizations that you have partnered with during this reporting period and to indicate how formal the relationship is. By partnering we mean a sharing of time, money, personnel, planning or other resources.

84. Do you feel it is important for you to partner with youth groups in order to meet the goals and objectives of your SPF-SIG intervention? We would like your honest answer. You will not be penalized if you respond with No. We understand that for some interventions or problems it is not necessary to partner with this type of group. (Select yes or no.)

Yes

No

85. Have you partnered with youth groups (e.g., local youth councils, church youth groups, youth recreation leagues)? (Select yes or no.)

Yes

No (If no, proceed to question 88.)

86. How many youth groups do you partner with?

____

87. Indicate how many of the youth groups you partner with fall into each of the categories below. The list of youth group partners at each degree of participation must equal the numeric response in Question 86. For example, if 8 youth groups were listed as partners in Question 86, Question 87 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of youth group partners at each level (Total should equal the response in question 86.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

88. Do you feel it is important for you to partner with parent/family/caregiver groups in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of group. (Select yes or no.)

Yes

No

89. Have you partnered with parent/family/caregiver groups? (Select yes or no.)

Yes

No (If no, proceed to question 92.)

90. How many parent/family/caregiver groups do you partner with?

____

91. Indicate how many of the parent/family/caregiver groups you partner with fall into each of the categories below. The list of parent/family/caregiver groups at each degree of participation must equal the numeric response in Question 90. For example, if 8 parent/family/caregiver groups were listed as partners in Question 90, Question 91 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of parent/family/caregiver groups at each level (Total should equal the response in question 90.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

92. Do you feel it is important for you to partner with the business community in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of community. (Select yes or no.)

Yes

No

93. Have you partnered with the business community? (Select yes or no.)

Yes

No (If no, proceed to question 96.)

94. How many businesses or business groups do you partner with?

____

95. Indicate how many of the members of the business community that you partner with fall into each of the categories below. The list of businesses at each degree of participation must equal the numeric response in Question 94. For example, if 8 businesses were listed as partners in Question 94, Question 95 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of businesses partnered with at each level (Total should equal the response in question 94.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

96. Do you feel it is important for you to partner with the media (e.g., radio and television stations, newspapers and magazines) in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with the media. (Select yes or no.)

Yes

No

97. Have you partnered with the media (e.g., radio and television stations, newspapers and magazines)? (Select yes or no.)

Yes

No (If no, proceed to question 100.)

98. How many media organizations or groups do you partner with?

____

99. Indicate how many of the media organizations or groups that you partner with fall into each of the categories below. The list of media partners at each degree of participation must equal the numeric response in Question 98. For example, if 8 media partners were listed in Question 98, Question 99 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of media partners at each level (Total should equal the response in question 98.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

100. Do you feel it is important for you to partner with schools in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with ”no.” We understand that for some interventions or problems it is not necessary to partner with schools. (Select yes or no.)

Yes

No

101. Have you partnered with schools or school districts? (Select yes or no.)

Yes

No (If no, proceed to question 105.)

102. How many schools do you partner with?

____

103. How many school districts do you partner with?

____

104. Indicate how many of the schools or school districts that you partner with fall into each of the categories below. The list of schools or school districts at each degree of participation must equal the numeric response in Question 102 or 103. For example, if 8 schools were listed in Question 102, Question 104 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of school partners at each level (Total should equal the response in question 102.)	Provide the number of school district partners at each level (Total should equal the response in question 103.)	Participation Level
a.	d.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	e.	This partner contributes at a level appropriate for its role in the partnership
c.	f.	This partner rarely or almost never participates

105. Do you feel it is important for you to partner with youth serving organizations (e.g., Big Brothers Big Sisters, Boy Scouts/Girl Scouts) in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of organization. (Select yes or no.)

Yes

No

106. Have you partnered with youth serving organizations (e.g., Big Brothers Big Sisters, Boy Scouts/Girl Scouts)? (Select yes or no.)

Yes

No (If no, proceed to question 109.)

107. How many youth serving organizations do you partner with?

____

108. Indicate how many of the youth serving organizations that you partner with fall into each of the categories below. The list of youth serving organizations at each degree of participation must equal the numeric response in 107. For example, if 8 youth serving organizations were listed in Question 107, Question 108 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of youth serving organization partners at each level (Total should equal the response in question 107.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

109. Do you feel it is important for you to partner with law enforcement agencies such as local and state police, FBI, and the Drug Enforcement Administration (DEA) in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of agency. (Select yes or no.)

Yes

No

110. Have you partnered with law enforcement agencies (e.g., local and state police, FBI, DEA)? (Select yes or no.)

Yes

No (If no, proceed to question 113.)

111. How many law enforcement agencies do you partner with?

____

112. Indicate how many of the law enforcement agencies that you partner with fall into each of the categories below. The list of law enforcement agencies at each degree of participation must equal the numeric response in Question 111. For example, if 8 law enforcement agencies were listed in Question 111, Question 112 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of law enforcement agency partners at each level (Total should equal the response in question 111.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

113. Do you feel it is important for you to partner with local or state courts in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with these courts. (Select yes or no.)

Yes

No

114. Have you partnered with local or state courts? (Select yes or no.)

Yes

No (If no, proceed to question 117.)

115. How many local or state courts do you partner with?

____

116. Indicate how many local or state courts that you partner with fall into each of the categories below. The list of local or state courts at each degree of participation must equal the numeric response in Question 115. For example, if 8 local or state courts were listed in Question 115, Question 116 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of courts partnered with at each level (Total should equal the response in question 115.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

117. Do you feel it is important for you to partner with the Federal Department of Justice in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this department. (Select yes or no.)

Yes

No

118. Have you partnered with the Federal Department of Justice? (Select yes or no.)

Yes

No (If no, proceed to question 121.)

119. How many Federal Department of Justice units do you partner with?

____

120. Indicate how many Federal Department of Justice units that you partner with fall into each of the categories below. The list of Federal Department of Justice units at each degree of participation must equal the numeric response in Question 119. For example, if 8 courts or Department of Justice entities were listed in Question 119, Question 120 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of Department of Justice units partnered with at each level (Total should equal the response in question 119.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

121. Do you feel it is important for you to partner with local or state jails or prisons in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with jails or prisons. (Select yes or no.)

Yes

No

122. Have you partnered with local or state jails or prisons? (Select yes or no.)

Yes

No (If no, proceed to question 125.)

123. How many local or state jails or prisons do you partner with?

____

124. Indicate how many of the local or state jails or prisons that you partner with fall into each of the categories below. The list of local or state jails or prisons at each degree of participation must equal the numeric response in Question 123. For example, if 8 local or state jails or prisons were listed in Question 123, Question 124 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of jails or prisons partnered with at each level (Total should equal the response in question 123.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

125. Do you feel it is important for you to partner with faith-based organizations (e.g., churches or charitable organizations with religious affiliations such as Catholic Charities) in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of partner. (Select yes or no.)

Yes

No

126. Have you partnered with faith-based organizations (e.g., churches or charitable organizations with religious affiliations such as Catholic Charities)? (Select yes or no.)

Yes

No (If no, proceed to question 129.)

127. How many faith-based organizations do you partner with?

____

128. Indicate how many of the faith-based organizations that you partner with fall into each of the categories below. The list of faith-based organizations at each degree of participation must equal the numeric response in Question 127. For example, if 8 faith-based organizations were listed in Question 127, Question 128 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of faith-based organization partners at each level (Total should equal the response in question 127.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

129. Do you feel it is important for you to partner with civic or volunteer organizations (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations) in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of organization. (Select yes or no.)

Yes

No

130. Have you partnered with civic or volunteer organizations (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)? (Select yes or no.)

Yes

No (If no, proceed to question 133.)

131. How many civic or volunteer organizations do you partner with?

____

132. Indicate how many of the civic or volunteer organizations that you partner with fall into each of the categories below. The list of civic or volunteer organizations at each degree of participation must equal the numeric response in Question 131. For example, if 8 civic or volunteer organizations were listed in Question 131, Question 132 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of civic or volunteer organization partners at each level (Total should equal the response in question 131.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

133. Do you feel it is important for you to partner with healthcare professionals in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with healthcare professionals. (Select yes or no.)

Yes

No

134. Have you partnered with healthcare professionals? (Select yes or no.)

Yes

No (If no, proceed to question 137.)

135. How many healthcare professionals do you partner with?

____

136. Indicate how many of the healthcare professionals that you partner with fall into each of the categories below. The list of healthcare professionals at each degree of participation must equal the numeric response in Question 135 For example, if 8 healthcare professionals were listed in Question 135, Question 136 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of healthcare professionals partnered with at each level (Total should equal the response in question 135.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

137. Do you feel it is important for you to partner with state government agencies (e.g., public health, public safety, social services) in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of agency. (Select yes or no.)

Yes

No

138. Have you partnered with state government agencies (e.g., public health, public safety, social services) that have expertise in substance abuse? (Select yes or no.)

Yes

No (If no, proceed to question 141.)

139. How many state government agencies do you partner with?

____

140. Indicate how many of the state government agencies that you partner with fall into each of the categories below. The list of state government agencies at each degree of participation must equal the numeric response in Question 139. For example, if 8 state government agencies were listed in Question 139, Question 140 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of state government agency partners at each level (Total should equal the response in question 139.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

141. Do you feel it is important for you to partner with local, village or tribal agencies (e.g., Mayor’s Office, city councils, tribal councils), including those funded by the state, in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of agency. (Select yes or no.)

Yes

No

142. Have you partnered with local, village or tribal agencies (e.g., Mayor’s Office, city councils, tribal councils) that have expertise in substance abuse? (Select yes or no.)

Yes

No (If no, proceed to question 145.)

143. How many local, village or tribal agencies do you partner with?

____

144. Indicate how many of the local, village or tribal agencies that you partner with fall into each of the categories below. The list of local, village, or tribal government agencies at each degree of participation must equal the numeric response in Question 143. For example, if 8 local, village, or tribal government agencies were listed in Question 143, Question 144 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of local, village, or tribal government agency partners at each level (Total should equal the response in question 143.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

145. Have you partnered with other groups/organizations? (Select yes or no.)

Yes

No (If no, proceed to question 150.)

146. Describe the other type(s) of groups/organizations worked with in 25 words or less. (Provide a concise written description in the space available.)

147. Do you feel it is important for you to partner with these other groups/organizations in order to meet the goals and objectives of your SPF SIG intervention? We would like your honest answer. You will not be penalized if you respond with “no.” We understand that for some interventions or problems it is not necessary to partner with this type of group/organization. (Select yes or no.)

Yes

No

148. How many of these other groups/organizations do you partner with?

____

149. Indicate how many of the other groups/organizations that you partner with fall into each of the categories below. The list of other groups or organizations at each degree of participation must equal the numeric response in Question 148. For example, if 8 other groups or organizations were listed in Question 148, Question 149 responses could be that 1 partner is an active participant, 5 are appropriately engaged partners, and 2 rarely or almost never participate, totaling 8.

Provide the number of other organization partners at each level (Total should equal the response in question 148.)	Participation Level
a.	This partner is a valuable and active participant in the partnership and contributes at a level above and beyond what is expected
b.	This partner contributes at a level appropriate for its role in the partnership
c.	This partner rarely or almost never participates

150. Did you receive SPF SIG funded guidance, training or technical assistance with regard to building relationships (Web programming note: definition link)? Do not include training that you are going to receive in the future. You will be able to report this in future reports. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 152.)

151. How likely is it that you will use what you learned during the guidance, training or technical assistance on building relationships in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

152. If your project experienced any challenges with relationship building during this reporting period, please describe them here. Examples might include challenges involving a key stakeholder (Web programming note: definition link), working with the Single-State Agency (SSA) and its partners, or obtaining community support. (Provide a concise written description in the space available.)

153. If your project experienced any specific successes with relationship building during this reporting period, please describe them here. Examples might include success getting a key stakeholder (Web programming note: definition link) involved, working with the Single-State Agency (SSA) and its partners, or obtaining community support. (Provide a concise written description in the space available.)

Sustainability

This section asks about things you have done to ensure that intervention activities (Web programming note: definition link) and outcomes continue once SPF SIG funding ends. These efforts might focus on ensuring continued funding, structures, networks, partnerships, leadership, and resources.

154. Have you worked during this reporting period to ensure that the intervention activities and outcomes continue when SPF SIG funding ends? (Select yes or no.)

Yes

No (If no, proceed to question 156.)

155. How have you worked to ensure that intervention activities and outcomes continue after SPF SIG funding has ended? If you worked to get activities written into another organization’s operating procedures or way of doing business (e.g., convincing a school district to include substance abuse prevention as part of their annual health curriculum) this reporting period, select “Worked to ensure that intervention activities are incorporated into the mission/goals and activities of other organizations.” (Select all that apply.)

 Leveraged other funding sources

 Worked to ensure that intervention activities are incorporated in to the missions/goals and activities of other organizations

 Worked to implement local level laws, policies or regulations to guarantee the continuation of intervention activities

 Worked on developing coalition structure to ensure sustainability

 Other (Describe.)____________________________________

156. Did you receive SPF SIG funded guidance, training or technical assistance with regard to ensuring that intervention activities and outcomes continue after SPF SIG funding ends (Web programming note: definition link)? Do not include training that you are going to receive in the future. You will be able to report this in future reports. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 158.)

157. How likely is it that you will use what you learned during the guidance, training or technical assistance on ensuring that intervention activities and outcomes continue after SPF SIG funding ends in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

158. If your project experienced any challenges while working to ensure that intervention activities and outcomes continue after SPF SIG funding ends during this reporting period, please describe them here. The challenges might relate to ensuring sustainability of funding, project activities and/or project results and outcomes. (Provide a concise written description in the space available.)

159. If your project experienced any successes while working to ensure that intervention activities and outcomes continue after SPF SIG funding ends during this reporting period, please describe them here. The successes might relate to ensuring sustainability of funding, project activities and/or project results and outcomes. (Provide a concise written description in the space available.)

Strategic Plan Development

T

People you may want to include in responding to this section:

• Project Director

• Project Coordinator

• Coalition Members

his section collects information on the development of your strategic plan, including what is addressed in the plan and who has contributed to the plan at the local level.

160. Have you completed a strategic plan (Web programming note: definition link)? (Select yes or no.)

(Web programming note: Once answered yes, does not have to be answered again.)

Yes

No (If no, proceed to question 173.)

161. Who worked on the strategic plan (Web programming note: definition link)? (Select all that apply.) (Web programming note: Once answered, does not have to be answered again.)

 Youth

 Parents/family/caregiver groups

 Business community

 Media (e.g., radio and television stations, newspapers and magazines)

 Advocacy volunteers

 School(s)/school districts

 Youth serving organization(s) (other than school) (e.g., Big Brothers/Big Sisters, Boy Scouts/Girl Scouts)

 Law enforcement agency/agencies

 Faith-based organization(s) (e.g., churches or charitable organizations with religious affiliations such as Catholic Charities)

 Civic or volunteer organization(s) (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)

 Healthcare professionals

 State, local, village or tribal government agencies (e.g., social services, public health, etc.)

 Local evaluator

 Other (Describe.)________________________________________________________

162. Which of the following does the strategic plan address or include? (Select all that apply.)

 Data indicators on substance abuse

 Data on factors causing, leading to, or promoting substance use

 Underage drinking initiative

 Cultural competence

 Connection with state SPF SIG initiative

 Current community resources/strengths

 Identification of conditions outside the scope of the intervention (e.g., poverty rates, immigration trends, laws) that might affect it

 Logic model

 Necessary infrastructure development

 Role of stakeholders

 Appropriate interventions selected to match target outcomes or causal factors

 Barriers to implementation

 Measurable objectives

 Identification of available data sources to measure objectives

 Data collection plans

 Data monitoring plans

 Data analysis plans

 Sustainability

 Opportunity for adjustments based on initial outcomes

163. If you indicated in question 162 that your strategic plan includes a logic model, does the strategic plan also include a way to evaluate the relationships, activities and outcomes illustrated in the logic model (Web programming note: definition link)? (Select yes or no.)

Yes

No

164. Has your strategic plan been reviewed by the agency responsible for the SPF SIG initiative in your state? The agency responsible for the SPF SIG in your state may be called the single state agency, the SSA, or some other name. If you are unsure of what agency is responsible for the SPF SIG in your state, contact Shelly Kowalczyk at (301) 587-1600 or via email at skowalczyk@mayatech.com and she will help you identify the agency. (Select yes or no.)

Yes

No (If no, proceed to question 166.)

165. Have you received feedback on your strategic plan by the agency responsible for the SPF SIG initiative in your state? (Select yes or no.)

Yes

No

166. Has your strategic plan been approved by the agency responsible for the SPF SIG initiative in your state? (Select yes or no.)

Yes

No

Our state does not require or provide approval of the strategic plan.

167. Was the strategic plan revisited during this reporting period? It is expected that at some point you will revisit your strategic plan. Reevaluating your strategic plan is part of the Strategic Prevention Framework and does not imply that you made mistakes developing your original strategic plan. (Web programming note: this question needs to be asked every reporting period after the respondent indicates that the strategic plan was developed.) (Select yes or no.)

Yes

No (If no, proceed to question 171.)

168. If the strategic plan was revisited, were any changes made? (Select yes or no.)

Yes

No (If no, proceed to question 171.)

169. If the strategic plan was changed, indicate why it was changed. (Select all that apply.)

 New data indicated new priority areas

 Political considerations

 New technology made additional surveillance (Web programming note: definition link) or evaluation methods available

 Funding changes increased or decreased the scope of intervention activities

 Other (Describe.)________________________________________________________

170. Indicate areas where changes were made to the strategic plan after revisiting the plan. (Select all that apply.)

Data indicators on substance abuse

Data on factors causing, leading to, or promoting substance use

 Underage drinking initiative

 Cultural competence

 Connection with state SPF SIG initiative

 Current community resources/strengths

 Identification of conditions outside the scope of the intervention (e.g., poverty rates, immigration trends, laws) that might affect it

 Logic model

 Necessary infrastructure development

 Role of stakeholders

 Appropriate interventions selected to match target outcomes or causal factors

 Barriers to implementation

 Measurable objectives

 Identification of available data sources to measure objectives

 Data collection plans

 Data monitoring plans

 Data analysis plans

 Sustainability

 Opportunity for adjustments based on initial outcomes

(Web programming note: Questions 171-172 are only answered if the respondent indicated in question 162 that the strategic plan included a logic model.)

171. Was the logic model (Web programming note: definition link) revised during this reporting period? (Select yes or no.)

Yes

No (If no, proceed to question 173.)

172. Indicate why the logic model (Web programming note: definition link) was revised. (Select all that apply.)

 New data indicated new priority areas

 Political considerations

 New technology made additional surveillance (Web programming note: definition link) or evaluation methods available

 Funding changes increased or decreased the scope of intervention activities

 Other (Describe.)________________________________________________________

173. Did you receive SPF SIG funded guidance, training or technical assistance with regard to developing a strategic plan (Web programming note: definition link) during this reporting period? Do not include training that you are going to receive in the future. You will be able to report this in future reports. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 175.)

174. How likely is it that you will use what you learned during the guidance, training or technical assistance on developing a strategic plan in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

175. Did you receive SPF SIG funded guidance, training or technical assistance with regard to selecting interventions (Web programming note: definition link) during this reporting period? Do not include training that you are going to receive in the future. You will be able to report this in future reports. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 177.)

176. How likely is it that you will use what you learned during the guidance, training or technical assistance on selecting interventions in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

177. If your project experienced any challenges with developing the strategic plan during this reporting period, please describe them here. (Provide a concise written description in the space available.)

178. If your project experienced any specific successes with developing the strategic plan during this reporting period, please describe them here. (Provide a concise written description in the space available.)

Intervention Implementation

This section collects information about the intervention(s) you selected for implementation (Web programming note: definition link) in your community. An intervention is an activity or set of activities to which a group is exposed in order to change the group's behavior. In substance abuse prevention, interventions are used to prevent or lower the rate of substance abuse or substance abuse-related problems.

179. D

     People you may want to include in responding to this section:

     • Project Director

     • Project Coordinator

     • State Epidemiology Workgroup (SEOW) Liaison

     • Intervention delivery staff

     id you work on intervention implementation (Web programming note: definition link) during this reporting period? (Select yes or no.)

Yes

No (If no, proceed to question 181.)

For question 180 below, name the intervention(s) (Web programming note: definition link) you implemented/delivered during this reporting period.

180. Intervention Name

a.

b.

c.

(Table will automatically generate new lines to add more interventions. (Web planning note: For each intervention named, the respondent will need to complete a new Part II form, the intervention form.)

181. Did you receive SPF SIG funded guidance, training or technical assistance with regard to recruiting participants for interventions during this reporting period? Do not include training that you are going to receive in the future. You will be able to report this in future reports. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 183.)

Not applicable (If not applicable, proceed to question 183.)

182. How likely is it that you will use what you learned during the guidance, training or technical assistance on recruiting participants in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

183. If your project experienced any challenges with intervention implementation (Web programming note: definition link) during this reporting period, please describe them here. Examples might include challenges obtaining approval from an Institutional Review Board (IRBs are boards that review research projects to ensure that human participants are protected from harm), recruiting participants for interventions, maintaining contact with participants for follow-up data collection, or challenges implementing environmental strategies. (Provide a concise written description in the space available.)

184. If your project experienced any specific successes related to intervention implementation (Web programming note: definition link) during this reporting period, please describe them here. Examples might include obtaining approval from an Institutional Review Board (IRBs are boards that review research projects to ensure that human participants are protected from harm), working with another organization to recruit participants, or launching a new environmental strategy. (Provide a concise written description in the space available.)

Monitoring and Evaluation

This section collects information on your development of an evaluation plan (Web programming note: definition link). You are also asked to indicate whether a final evaluation report was developed and if key findings from the evaluation were distributed to stakeholders/key informants (Web programming note: definition link).

185. W

     People you may want to include in responding to this section:

     • Project Director

     • Project Coordinator

     • Evaluator

     as intervention implementation (Web programming note: definition link) monitored by the Single State Agency (SSA) or state agency in charge of the SPF SIG funding during this reporting period? (Select one response.)

 Yes

 Implementation of some interventions was monitored, but not all interventions were monitored.

 No

 Don’t know

186. Did you work on intervention level evaluation activities (Web programming note: definition link) during this reporting period? (Select yes or no.)

Yes

No (If no, proceed to question 194.)

187. Have you developed an evaluation plan? (Select yes or no.)

Yes

No (If no, proceed to question 190.)

188. Was the evaluation plan revised during this reporting period? (Select yes or no.)

Yes

No (If no, proceed to question 190.)

189. Indicate how the evaluation plan was revised. (Select all that apply.)

Immediate outcomes (Web programming note: definition link) were changed

Intermediate outcomes (Web programming note: definition link) were changed

Instruments or assessment tools were changed

Data collection points (intervals between pre- and post-test or follow-up) were changed

Analysis plans were changed

Plans for dissemination of evaluation results were changed

Other (Describe.) _______________________________________________________

190. Did you develop any evaluation reports during this reporting period? Evaluation reports could take the form of letters, emails, formal reports, presentations or other formats. (Select yes or no.)

Yes

No

191. Did you communicate any evaluation findings to key stakeholders (Web programming note: definition link)/key informants during this reporting period? (Select yes or no.)

Yes

No (If no, proceed to question 194.)

192. If so, how did you communicate the findings? (Select all that apply.)

Distributed written report to stakeholders

Presented findings at a meeting of stakeholders

Presented findings to community members/participants

Written press release

Televised press conference

Other (Describe.)________________________________________________________

193. Indicate how stakeholders used these evaluation findings. (Select all that apply.)

To set policy

To change substance abuse priorities

To leverage additional funds

To recruit additional partners

To leverage additional prevention staff

To encourage coordination among organizations or agencies

To learn/increase knowledge

Other (Describe.)________________________________________________________

Don’t know (Web programming note: If this option is selected, respondent should not be able to select others.)

194. Did you receive SPF SIG funded guidance, training or technical assistance with regard to evaluation activities during this reporting period? Do not include training that you are going to receive in the future. You will be able to report this in future reporting periods. We are specifically asking about guidance, training or technical assistance that was paid for with SPF SIG funds. If you are not sure if the guidance, training or technical assistance you received was paid for with SPF SIG funds, contact your local or state SPF SIG director. (Select yes or no.)

Yes

 No (If no, proceed to question 196.)

195. How likely is it that you will use what you learned during the guidance, training or technical assistance on evaluation activities in your SPF SIG activities? We would like your honest answer. You will not be penalized if you mark “not likely.” (Select one response.)

Very likely

 Somewhat likely

Not likely

196. If your project experienced any challenges with intervention evaluation during this reporting period, please describe them here. Examples might include challenges identifying measures, collecting evaluation data, or analyzing data. (Provide a concise written description in the space available.)

197. If your project experienced any specific successes with intervention evaluation during this reporting period, please describe them here. Examples might include completing a series of follow-up data collections or publishing and disseminating findings of intervention evaluation. (Provide a concise written description in the space available.)

Systems Factors

For purposes of this instrument, the prevention system is “the entire set of agencies, organizations, and persons that contribute to efforts to prevent substance abuse and related problems within the community.” Keep this in mind as you answer the questions below about planning and data systems.

198. Does your community have a specific plan or vision/mission statement about substance abuse prevention that guides the community substance abuse prevention planning process? (Select yes or no.)

Yes

No (If no, proceed to question 200.)

199. If yes, describe the primary goals of the plan or vision/mission statement. (Provide a concise written description in the space available.)

200. Does your community have a written, documented process for making substance abuse prevention-related decisions? (Select yes or no.)

Yes

No (If no, proceed to question 203.)

201. Describe the basic steps in the process. (Provide a concise written description in the space available.)

202. Who is involved in making substance abuse prevention-related decisions? (Provide a concise written description in the space available.)

203. Do multiple organizations and agencies in your community work together to collect, manage and organize community ATOD data? (Select yes or no.)

Yes (If yes, proceed to question 205.)

No

204. If you answered no to question 203, please describe why not. After answering this question, proceed to question 206. (Provide a concise written description in the space available.)

205. If you answered yes to question 203, please describe the types of community data collected by these organizations. (Provide a concise written description in the space available.)

206. Is there a primary organization or agency that has responsibility for management of the data? (Select yes or no.)

Yes

No (If no, proceed to question 208.)

207. How was this organization selected to manage the data? (Provide a concise written description in the space available.)

208. Do you have access to prevention data systems? These data systems might include data on Alcohol, Tobacco, and other Drug (ATOD) consumption, ATOD related problems and consequences, and/or ATOD prevention capacity. (Select yes or no.)

Yes

No (If no, proceed to question 210.)

209. Describe the types of data systems you have access to. (Provide a concise written description in the space available.)

Contextual Factors

Contextual factors are conditions that exist outside the scope of the intervention activities, but nevertheless influence the SPF process and intervention delivery. While you can incorporate knowledge of these factors into your planning and interventions (Web programming note: definition link), they typically cannot be changed through intervention activities. Understanding the nature of contextual factors, however, is still helpful in evaluating the success of the intervention (Web programming note: definition link). For purposes of the cross-site evaluation, contextual factors are categorized by demographic factors (Web programming note: definition link), cultural factors (Web programming note: definition link), community factors (Web programming note: definition link), and environmental/systems factors (Web programming note: definition link).

(Web planning note: All respondents will have to complete this section every reporting period.)

People you may want to include in responding to this section:

• Project Director

• Project Coordinator

• Intervention delivery staff

• Evaluator

• Coalition representative

210. Describe here any demographic factors or issues (Web programming note: definition link) that have had an impact or will have an impact on prevention activities in your community during this reporting period. Potential demographic factors include population density, immigration trends, poverty rates, literacy rates or employment rates. Make sure to include a specific description of the issue and how it affected or might affect your intervention activities. If the issue presented a challenge for you, indicate how you are overcoming the challenge or how you plan to overcome the challenge. (Provide a concise written description in the space available.)

211. Describe here any cultural factors (Web programming note: definition link) that have had an impact or will have an impact on prevention activities in your community during this reporting period. Potential cultural factors include parental/family/caregiver ambivalence about drug/alcohol use among youth; language, or skepticism or mistrust of government-sponsored programs or law enforcement. Make sure to include a specific description of the issue and how it affected or might affect your intervention activities. If the issue presented a challenge for you, indicate how you are overcoming the challenge or how you plan to overcome the challenge. (Provide a concise written description in the space available.)

212. Describe here any community factors (Web programming note: definition link) that have had an impact or will have an impact on prevention activities in your community during this reporting period. Potential community factors include level of community readiness; community attitudes and norms towards drug/alcohol use; access to drugs/alcohol; state/local government funding for substance abuse prevention and treatment; transportation issues; or local political processes or dynamics. Make sure to include a specific description of the issue and how it affected or might affect your intervention activities. If the issue presented a challenge for you, indicate how you are overcoming the challenge or how you plan to overcome the challenge. (Provide a concise written description in the space available.)

213. Describe here any environmental or systems factors (Web programming note: definition link) that have had an impact or will have an impact on prevention activities in your community during this reporting period. Potential environmental factors include state or local laws, policies or regulations; organizational policies (businesses, recreational leagues, schools, etc.); coordination among organizations/agencies; access to policy makers; or resources (time, funding, volunteers) dedicated to substance abuse prevention at the state or local level. Make sure to include a specific description of the issue and how it affected or might affect your intervention activities. If the issue presented a challenge for you, indicate how you are overcoming the challenge or how you plan to overcome the challenge. (Provide a concise written description in the space available.)

Closing Questions

214. Do you have any additional comments about any aspects of the SPF SIG Initiative? (Provide a concise written description in the space available.)

215. Did following the steps of the Strategic Prevention Framework during this reporting period lead to specific successes within your community in dealing with substance abuse prevention? Examples of success might include achieving intended outcomes, but also might include bringing needed stakeholders to the table or clearly identifying needs in the community. (Select yes or no.)

Yes

No (If no, proceed to question 217, if applicable.)

Too soon to determine (If marked, proceed to question 217, if applicable.)

216. If yes, please describe how following the specific steps of the framework contributed to your success, and what you consider a success. (Provide a concise written description in the space available.)

Coalition Sub-Form

This form should be completed by those community partners that are operating as a community coalition. Only complete this sub-form if you answered in question 21 that you are operating as a community coalition.

217. Who is the lead agency for the community coalition (the agency responsible for making the primary decisions of the coalition and/or the agency controlling the money)? (Provide a concise written description in the space available.)

218. Does this agency have financial responsibility for the coalition (Web programming note: definition link)? For example, is the agency responsible for ensuring that any paid positions receive their payment or for providing authorization for the purchase of supplies? (Select one response.)

Yes

No

Don’t know

219. Does the community coalition (Web programming note: definition link) have a funding source? (Select one response.)

Yes

No

Don’t know

220. Does the project director for the SPF SIG project work for the coalition’s lead agency? (Select one response.)

Yes

No

Don’t know

221. Does the community coalition (Web programming note: definition link) have an identifiable leader (an individual, not an agency)? (Select one response.)

Yes

No

Don’t know

222. Is the leader of the coalition (Web programming note: definition link) a paid position? (Select one response.)

Yes

No

Don’t know

For questions 223 through 231, indicate whether you strongly agree, agree, neither agree nor disagree, disagree or strongly disagree with the statement.

223. The coalition has a clear vision and focus. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

224. The community coalition (Web programming note: definition link) has collaborative leadership. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

225. Responsibilities among coalition members are fairly and effectively delegated. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

226. The coalition (Web programming note: definition link) has a broad-based, diverse membership that represents the various groups and organizations involved in substance abuse prevention. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

227. There is too much talking and not enough follow through with actions. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

228. The coalition has a process for tracking decisions. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

229. The coalition does not monitor whether or not there is follow through on decisions. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

230. The coalition needs more structure in order to be effective. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

231. Denial and apathy among community members toward local substance use issues is a major barrier to our coalition’s effectiveness. (Select one response.)

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Strategic Prevention Framework

State Incentive Grant

(SPF SIG)

Cross-Site Evaluation

Community Level Instrument

(Part II):

Intervention Strategies

July 2006

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Prevention

Form Approved

OMB No. XXXX-XXXX

Expiration Date XX/XX/XXXX

Burden Statement: Public reporting burden of this collection of information is estimated to average XX hours per response.  Send all comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, Choke Cherry Road, Rockville, MD 20857.  An agency may not sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  The control number for this project is XXXX-XXXX.

SPF SIG Cross-Site Evaluation, Community Level Instrument, Part II

Intervention Form

Information and Directions 3

Intervention Information 4

Adaptations 9

Intervention Outcomes 12

Closing Question 13

Prevention Education Sub-Form 14

Alternative Drug-Free Activities Sub-Form 18

Problem Identification and Referral Sub-Form 22

Community-Based Processes Sub-Form 25

Environmental Strategies Sub-Form 28

Information Dissemination Sub-Form 43

Other Activities or Services Delivered to Individuals Sub-Form 46

Other Activities or Services Not Delivered to Individuals Sub-Form 50

Intervention Form

Information and Directions

This instrument is designed to collect information about the activities of the community partners for the Strategic Prevention Framework -State Incentive Grant (SPF-SIG) Initiative. This information will be collected every 6 months, with a select number of questions being asked only once throughout the life of the grant.

The CLI is designed as a two-part survey. Part I collects data about the community’s progress through the strategic prevention framework. Part II collects information about the specific intervention(s) being implemented by the community. The community will complete a separate Part II form for each intervention implemented. For example, if the community is implementing both a participant-based, education intervention and an environmental intervention, they will complete two Part II forms. Data collected from the survey will be used to evaluate the effectiveness of the Strategic Prevention Framework.

Completion of this survey is a requirement of accepting funding from CSAP under the SPF SIG grant initiative. However, respondents may choose not to answer a specific question and respondents may end the survey at any time. Each community partner will be assigned a unique numerical identification. This identification will be used to ensure that communities cannot be identified. In addition, no individuals will be identified in the reporting of results.

Make sure to read all of the directions and examples, which are provided in italics.

Directions for skipping questions are indicated where appropriate to minimize the time needed to complete the questionnaire. This web-based survey is designed to automatically take you to the appropriate question, but you should still follow the directions closely.

Throughout this instrument, words that are underlined are hyperlinked to a list of definitions. In addition, if you click here you can access SAMHSA’s prevention glossary as well. (Web programming note: include link to: http://preventionplatform.samhsa.gov/MacroHQ/Glossary2/dssglossary.cfm?sect_id=1&topic_id=99&CFID=261427&CFTOKEN=54631918 .)

Throughout this document, the term “you” refers to the community partner that has received SPF SIG funding from the state. This could be an organization, coalition, or other entity. If this community partner is a community coalition, the Project Director for the SPF SIG project is required to complete the instrument, with input from other coalition members as needed.

You are strongly encouraged to obtain input from others involved with the SPF SIG funded project. Each section of the instrument includes a list of individuals whom you may want to consider asking to assist you in this data collection process. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, such as the project coordinator, evaluator, intervention delivery staff, and others, as appropriate.

As you enter your data, you will be able to save your work and come back to it at another time. You may also write your responses to the narrative response questions in a word processor and copy and paste them into the web-based survey.

I

People you may want to include in responding to this form:

• Project Director

• Project Coordinator

• Intervention delivery staff

• Evaluator

• Coalition representative(s)

f you need assistance in completing this instrument, contact Shelly Kowalczyk at (301) 587-1600 or via e-mail at skowalczyk@mayatech.com

Intervention Information

1. Name of the intervention (Web programming note: definition link). (Web programming note: This field will be auto-filled based on response in question 183 in Part I.)

________________________________________

2. When did you begin funding this intervention? (Provide MM/YYYY.)

MM/YYYY ____________

3. When did you complete implementing this intervention? If you are currently implementing this intervention, leave this response blank. (Provide MM/YYYY) (Web programming note: This question must be asked every time until the intervention is complete and an answer is provided.)

MM/YYYY ____________

4. What factors, beyond data driven planning, influenced your intervention selection? (Select all that apply.)

 Local capacity to deliver interventions

 Cost

 Experience implementing intervention prior to SPF SIG funding

 Political environment

 Requirements of partnering organizations

 Evidence-based literature on effectiveness

 Other information supporting the effectiveness of the intervention

 Demographics or cultural characteristics of local population

 Availability of technical assistance

 Recommendation by state funding agency

 Other (Describe.)

5. Is this an evidence-based program, policy or practice (Web programming note: definition link)? (Select yes or no.)

 Yes

 No (If no, proceed to question 7.)

6. How do you know this is an evidence-based program, policy or practice (Web programming note: definition link)? (Select all that apply.)

 We did not use any specific criteria to determine that this was an evidence-based program, policy or practice

 Evaluator recommendation

 Listed in National Registry of Effective Programs and Practices (NREPP)

 Listed on some other federal agency or national organization’s list of “effective programs”

 Found to be effective in a peer-reviewed journal article

 Based on a theory or conceptual model

 Implemented in a similar community

 CSAP recommendation

 Center for the Application of Prevention Technologies (CAPT) Web site

 Other (Describe.)

7. Is this a new intervention developed and tested by you, the community partner? Some communities are funded to create new interventions for specific target populations, substances and consequences that have been identified as problem areas in the community. If your intervention is one you developed and have tested or are planning on testing with a target population select “yes.” (Select yes or no.)

 Yes (Web programming note: If yes, the respondent will skip questions 25-38.)

 No (If no, proceed to question 10.)

8. If the intervention you are developing is based on an evidence-based program, policy or practice (Web programming note: definition link), provide the name of that intervention. If you do not know the full name of the intervention, provide the name you use. For example, you may have developed a new intervention, but used Life Skills Training as a starting point for your newly designed intervention. Provide as much information as necessary for clarification.

9. Indicate why you decided to develop a new intervention rather than using a previously tested intervention. (Select all that apply.)

 Previously tested interventions did not address the need in our community

 Previously tested interventions were not culturally appropriate

 Previously tested interventions were too costly

 Other (Describe.)

10. Which of the following best describes this intervention? (Select one response.)

 Not implemented in the community prior to SPF SIG funding (If marked, proceed to question 12.)

 Continuation of an intervention with no change (If marked, proceed to question 12.)

 Continuation of an intervention with changes or adaptations

11. If the intervention is the continuation of an intervention with changes or adaptations, describe the changes or adaptations and the reasons for the changes.

12. Is your definition of community based on something other than geography, such as a target population? (Select yes or no.)

 Yes (If yes, proceed to question 18.)

 No

For questions 13 through 17 below, indicate the areas being served by this intervention and the estimated population of this area. Use one line to describe each area. You only need to complete those categories that are appropriate for your intervention and community served. For example, if you are implementing a countywide environmental intervention, it makes sense to provide the name of the county, but it would not make sense to list all of the zip codes that are in that county. On the other hand, if you are implementing a neighborhood-based intervention, you would list the zip codes of the area being served.

City/Town	County/ Parish	Zip code(s)	Other geographic areas, including statewide (Describe.)	What is the estimated population for the area described?
a.
b.
c.

18. Of the total SPF SIG funding you received, what was the amount spent on this entire intervention--including planning, developing, implementing and evaluating the intervention--during this reporting period? Make sure to include overhead and salary costs in the amount. If you do not know the exact amount spent, respond with the best numeric estimate. (Round to the nearest dollar.)

$____________

19. Approximately what percentage of total funding for this intervention comes from SPF SIG funds? If you do not know the exact amount allocated, respond with your best numeric estimate. For example, if you received about a third of your funding for this intervention from SPF SIG funds, respond with 33%.

_______ %

20. Indicate the CSAP domain this intervention targets: (Select all that apply.)

For more information on CSAP’s domains, visit the Web site listed here:

http://www.northeastcapt.org/science/pod/agencyInfo.asp?caller=

 Individual domain (Web programming note: definition link)

 Family domain (Web programming note: definition link)

 Peer domain (Web programming note: definition link)

 School domain (Web programming note: definition link)

 Community domain (Web programming note: definition link)

 Society/Environmental domain (Web programming note: definition link)

21. Indicate the component(s) that are included in this intervention. Interventions may employ several different components: (Select all that apply.)

 Prevention education (Web programming note: definition link – if selected, the respondent will be routed to the prevention education form after completing the Intervention Form.)

 Alternative drug-free activities (Web programming note: definition link – if selected, the respondent will be routed to the alternatives to substance use component sub-form after completing the Intervention Form.)

 Problem identification and referral (Web programming note: definition link – if selected, the respondent will be routed to the problem identification and referral form after completing the Intervention Form.)

 Community based processes (Web programming note: definition link – if selected, the respondent will be routed to the community based processes form after completing the Intervention Form)

 Environmental strategies (Web programming note: definition link – if this option is selected the respondent will be routed to the environmental strategies form after completing the Intervention Form.)

 Information dissemination (Web programming note: definition link – if this option is selected the respondent will be routed to the information dissemination form after completing the Intervention Form.)

 Other activities or services delivered to individuals (Describe.)_____________________ (Web programming note: if this option is selected the respondent will be routed to the other activities or services delivered to individuals form after completing the Intervention Form.)

 Other activities or services not delivered to individuals (Describe.)_______________ (Web programming note: if this option is selected the respondent will be routed to the other activities or services delivered to individuals form after completing the Intervention Form.)

22. Does this intervention include a curriculum or manual (Web programming note: definition link)? By curriculum or manual, we mean a set of instructions about how to deliver the intervention. This can be a pre-existing curriculum or manual created by the intervention developer or a formal curriculum or manual developed by the community partner. (Select yes or no.)

 Yes

 No

23. Have any individual participants been served by this intervention during this reporting period, for example in classroom-based interventions or other direct service interventions? (Select yes or no.)

 Yes

 No (If no, proceed to next section, Adaptations.)

24. How many new participants (Web programming note: definition link) were served by this intervention during this reporting period? New participants are participants who had not received or participated in the intervention before and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best numeric estimate.

_____________

25. Of the total number of new participants served by this intervention during this reporting period (reported in question 24), indicate how many were male and how many were female. This should be an actual number and not a percentage. (Write a numeric response.)

Number of females:_____________

Number of males:______________

26. Of the total number of new participants served by this intervention during this reporting period (reported in question 24), indicate how many were in each of the age groups listed below. This should be an actual number and not a percentage. (Write a numeric response.)

Children age 0 to 3:_____________

Children age 4 to 5:_____________

Children age 6 to 11:_____________

Youth age 12 to 17:_____________

Young adults age 18 to 20:_____________

Young adults age 21 to 24:_____________

Adults age 25 to 55:_____________

Adults age 56 to 65:_____________

Adults age 66 and over:_____________

Adaptations

This section asks for information about any adaptations you made to this evidence-based program, policy or practice (Web programming note: definition link). We understand that making adaptations to an intervention can help make it more accessible to a specific population and we would like your honest answers about adaptations you may have made. Adaptations may include changes in target population, content, cultural appropriateness, dosage (Web programming note: definition link), duration (Web programming note: definition link), or setting (Web programming note: definition link) of the intervention that are different from those recommended by the intervention developer.

27. Did you adapt the intervention in order to deliver it to a target population that was not indicated by the developer? (Examples of adaptations include, targeting an age group younger than the indicated target population or targeting young men having sex with men as opposed to young adults ages 18-24 as indicated by the developer.) (Select one response.)

 Yes

 No (If no, proceed to question 29.)

 Intervention developer makes no recommendations for target population (If marked, proceed to question 29.)

 Not applicable (If not applicable, proceed to question 29.)

28. Describe the adaptation you made in order to deliver the intervention to a target population that was not indicated by the developer. (Provide a concise written description in the space available.)

29. Did you make any adaptation to the curriculum or manual content of the intervention? (Select one response.)

 Yes

 No (If no, proceed to question 31.)

 Intervention developer makes no recommendations for curriculum or manual content (If marked, proceed to question 31.)

 Not applicable (If not applicable, proceed to question 31.)

30. Describe the adaptation made to the curriculum or manual content. (Provide a concise written description in the space available.)

31. Did you make any adaptations to address the cultural appropriateness (Web programming note: definition link) of the intervention for a particular group? (Select one response.)

 Yes

 No (If no, proceed to question 33.)

 Intervention developer makes no recommendations regarding the cultural appropriateness of the intervention for different groups (If marked, proceed to question 33.)

 Not applicable (If not applicable, proceed to question 33.)

32. Describe the changes you made to improve the cultural appropriateness (Web programming note: definition link) of the intervention and how the fit was improved for a particular group. (Provide a concise written description in the space available.)

33. Did you adapt the recommended dosage for this intervention (e.g., the number of sessions or number of public service announcements (PSAs) or other media spots)? (Select one response.)

 Yes

 No (If no, proceed to question 36.)

 Intervention developer makes no recommendations for dosage (If marked, proceed to question 36.)

 Not applicable (If not applicable, proceed to question 36.)

34. Indicate the recommended dosage.

35. Indicate the dosage actually delivered.

36. Did you adapt the recommended duration (e.g., days or hours) of this intervention? (Select one response.)

 Yes

 No (If no, proceed to question 39.)

 Intervention developer makes no recommendations for duration (If marked, proceed to question 39.)

 Not applicable (If not applicable, proceed to question 39.)

37. Indicate the recommended duration, in hours, of this intervention.

hours

38. Indicate the number of hours actually spent delivering the intervention.

hours

39. Did you make an adaptation to the setting of the intervention (e.g., classroom, worksite, etc.)? (Select one response.)

 Yes

 No (If no, proceed to question 41.)

 Intervention developer makes no recommendations for setting (If marked, proceed to question 41.)

 Not applicable (If not applicable, proceed to question 41.)

40. Describe the adaptation made to the setting of the intervention (e.g., classroom, worksite, etc.). (Provide a concise written description in the space available.)

41. Did you collect information regarding participant satisfaction with the cultural appropriateness (Web programming note: definition link) of the intervention? (Select yes or no.)

 Yes

 No (If no, proceed to next section, Intervention Outcomes.)

42. What were the results of the assessment of participants’ satisfaction with the cultural appropriateness of the intervention? The results of an assessment of the cultural appropriateness of an intervention will vary greatly. For this reason, we have included broad response options of highly satisfied, moderately satisfied, and not satisfied. We ask that you analyze the results of your particular assessment and choose the category that best corresponds to the overall results of your assessment. (Select one response.)

 Participants were highly satisfied with cultural appropriateness.

 Participants were moderately satisfied with cultural appropriateness.

 Participants were not satisfied with cultural appropriateness.

 Not enough participants responded to adequately assess their satisfaction with the cultural appropriateness of the intervention.

Intervention Outcomes

This section pertains to the collection of outcome data (Web programming note: definition link). Outcome data is information that reveals the extent of change in targeted attitudes, values, behaviors, or conditions between baseline measurement and subsequent points of measurement. Depending on the nature of the intervention and the theory of change guiding it, changes can be immediate, intermediate, final, or longer-term outcomes.

If your intervention evaluation was conducted at the state level, questions 41 through 44 will be completed by the state. (Web programming note: we will need to set an on/off button for this section so that the state administrator can lock this section if the state is conducting the intervention evaluation.)

43. Were any outcome data (Web programming note: definition link) collected during this reporting period? This includes pretest, exit, and follow-up data, as well as other types of data. (Select yes or no.)

 Yes

 No (If no, proceed to question 47.)

44. If outcome data were collected, what was your sampling strategy? (Select all that apply.)

 The entire target population for the intervention

 Only the actual persons who directly participated in the intervention

 A specifically selected comparison group that did not receive the intervention

 Some other population or subgroup (Describe.)

45. Indicate the CSAP National Outcome Measures (NOMs) that are being collected. (Select all that apply.) If completing the Web-based version of this instrument, click here to visit CSAP’s information about NOMs. (Web programming note: include link to http://www.nationaloutcomemeasures.samhsa.gov/)

 30-day use

 Perceived risk of use

 Age of first use

 Perception of disapproval

 ATOD (Alcohol Tobacco and Other Drugs) suspensions/expulsions

 School attendance divided by enrollment (defined as attendance as a percentage of enrollment)

 Workplace ATOD (Alcohol Tobacco and Other Drugs) use

 Drug-related crime

 Alcohol-related car crashes and injuries

 Number of persons served by age, gender, race and ethnicity

 Total number of evidence-based interventions (Web programming note: definition link)

 Increased services provided within cost bands (Web programming note: definition link) for universal (Web programming note: definition link), selective (Web programming note: definition link), and indicated (Web programming note: definition link) programs.

46. Was an analysis of outcome data completed during this reporting period? This analysis could have been completed by the community partner, the state, or some other entity. In addition, this analysis could have been conducted by someone paid through the SPF SIG funds, or someone who was providing their services free-of-charge or as an in-kind contribution. (Select yes or no.)

 Yes

 No

Closing Question

47. Provide any additional comments about your prevention intervention activities here. (Provide a concise written description in the space available.)

Prevention Education Sub-Form

48. When did you first start serving participants with this Prevention Education component of the intervention, including all cycles? (Provide MM/YYYY.)

MM/YYYY ____________

49. Is this a recurring intervention, in which the same group of people are served over multiple intervention sessions? An example would be an intervention that is delivered to the same group of participants every Monday night for 6 weeks, or to an 8^th grade health class every Friday in a semester. (Select yes or no.)

 Yes

 No

50. Is the prevention education component of this intervention implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year? If your intervention takes place for a period of time with the same participants and then starts over with new participants, select “yes.” An intervention can be both recurring (question 49) and implemented in a series of cycles (question 50). (Select yes or no.)

 Yes

 No (If no, proceed to question 52.)

51. If the prevention education component of the intervention is implemented in cycles, what are the cycles based on? (Select one response.)

 The school calendar (quarters, semesters, school year)

 The SPF SIG funding cycle

 An organizational fiscal cycle

 Other (Describe.)

52. How many new groups of participants started the prevention education component of the intervention during this reporting period?

53. How many new groups of participants completed the prevention education component of the intervention during this reporting period?

54. What was the total number of sessions provided for each group of participants in the prevention education component of the intervention during this reporting period?

55. What was the average length of the individual sessions, in hours, during this reporting period?

hours

56. What was the format of the prevention education component of the intervention during this reporting period? (Select all that apply.)

 Individual

 Small group (2-9)

 Large group (10-49)

 Extra large group (50+)

 Web-based

 Other (Describe.)

57. Indicate the types of participants served by the prevention education component of the intervention during this reporting period. (Select all that apply.)

 Infants and children pre-school age and under

 Elementary school age children, including kindergarten

 Middle school or junior high school age youth

 High school age youth

 College students

 All individuals under age 21

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

58. As delivered, how would you classify this Prevention Education component according to the Institute of Medicine categories? (Select one response.)

 Universal (Web programming note: definition link)

 Selective (Web programming note: definition link)

 Indicated (Web programming note: definition link)

Use the table below to indicate the percentage of participants of each race served during the reporting period. Include all participants who were served by the prevention education component of this intervention during this reporting period.

If you do not know exact percentages of each race served, you may estimate percentages by determining the percentage of various races throughout the community using community/school profiles or community census data.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served by the prevention education component of this intervention during this reporting period who considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted. If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data.

Ethnic Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Alternative Drug-Free Activities Sub-Form

67. When did you first start serving participants with this Alternative Drug-Free Activities component of the intervention, including all cycles? (Provide MM/YYYY.)

MM/YYYY ____________

Questions 68 through 76 pertain to alternative drug-free activities that were targeted at a specific group, such as high school students, college students, etc.

68. Are these recurring activities, in which the same group of people is served over multiple intervention sessions? (Select yes or no.)

 Yes

 No

69. Is the alternative drug-free activities component of this intervention implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year? (Select yes or no.)

 Yes

 No (If no, proceed to question 71.)

70. If the alternative drug-free activities component of this intervention is implemented in cycles, what are the cycles based on? (Select one response.)

 The school calendar (quarters, semesters, school year)

 The SPF SIG funding cycle

 An organizational fiscal cycle

 Other (Describe.)

71. How many new groups of participants started the alternative drug-free activities component of this intervention during this reporting period?

72. How many new groups of participants completed the alternative drug-free activities component of this intervention during this reporting period?

73. What was the total number of sessions provided for each group of participants in the alternative drug-free activities component of this intervention during this reporting period?

74. What was the average length of the individual sessions, in hours, during this reporting period?

hours

75. What was the format of the alternative drug-free activities component of this intervention during this reporting period? (Select all that apply.)

 Individual

 Small group (2-9)

 Large group (10-49)

 Extra large group (50+)

 Web-based

 Other (Describe.)

76. Indicate the types of participants served by the alternative drug-free activities component of this intervention during this reporting period. (Select all that apply.)

 Infants and children pre-school age and under

 Elementary school age children, including kindergarten

 Middle school or junior high school age youth

 High school age youth

 College students

 All individuals under age 21

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

77. As delivered, how would you classify the alternative drug-free activities component of this intervention according to the Institute of Medicine categories? (Select one response.)

 Universal (Web programming note: definition link)

 Selective (Web programming note: definition link)

 Indicated (Web programming note: definition link)

Questions 78 through 80 pertain to alternative drug-free activities that were targeted at the general population, such as First Night Alcohol Free celebrations on New Year’s Eve.

78. Did you conduct drug-free events (concerts, festivals/fairs, picnics, sporting events) during this reporting period that were not targeted to specific groups of participants? (Select yes or no.)

 Yes

 No (If no, proceed to question 81.)

79. How many drug-free events were conducted during this reporting period?

80. How many people were reached through the drug-free events during this reporting period?

Use the table below to indicate the percentage of participants of each race served by the alternative drug-free activities component of this intervention during the reporting period.

If you do not know exact percentages of each race served, you may estimate percentages by determining the percentage of various races throughout the community using community/school profiles or community census data.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served by the alternative drug-free activities component of this intervention during this reporting period who considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted. If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data.

Ethnic Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Problem Identification and Referral Sub-Form

89. When did you first start serving participants with this Problem Identification and Referral component of the intervention, including all cycles? (Provide MM//YYYY.)

MM/YYYY ____________

90. Indicate the types of participants served by the Problem Identification and Referral component of this intervention during this reporting period. (Select all that apply.)

 Infants and children pre-school age and under

 Elementary school age children, including kindergarten

 Middle school or junior high school age youth

 High school age youth

 College students

 All individuals under age 21

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

91. What was the total number of individuals for whom problem identification and referral services were provided during this reporting period?

92. Where did problem identification and referral activities take place? (Select all that apply.)

 School

 Health care facilities

 Jails or prisons

 Courts

 Other (Describe.)

93. What type of services were individuals referred to? (Select all that apply.)

 Substance abuse treatment

 Mental health treatment

 Substance abuse prevention activities

 Housing services

 After school activities

 Transportation

 Day care or adult care services

 Other (Describe.)

Use the table below to indicate the percentage of participants of each race served by the problem identification and referral component of this intervention during the reporting period.

If you do not know exact percentages of each race served, you may estimate percentages by determining the percentage of various races throughout the community using community/school profiles or community census data.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served by the problem identification and referral component of this intervention during this reporting period that considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted. If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data.

Ethnic Category	a. Percentage of participants served	2. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Community-Based Processes Sub-Form

Indicate the activities that were conducted during this reporting period to enhance community resources (activities that will help the community address substance abuse and serve those with substance abuse problems), and provide activity details if asked.

102. Indicate the number of task force/coalition members you recruited during this reporting period, if any:

(If you did not do any work related to task forces or coalitions during this reporting period, proceed to question 105.)

103. Indicate the number of task force/coalition meetings you held during this reporting period, if any:

104. Indicate the number of task force/coalition members you trained during this reporting period, if any:

105. Indicate the number of other community members you trained during this reporting period, if any:

106. Did you coordinate funding with other organizations/projects during this reporting period? (Select yes or no.)

 Yes

 No

107. Did you develop interagency coordination mechanisms during this reporting period? (Select yes or no.)

 Yes

 No

108. Did you develop prevention or provider networks during this reporting period? (Select yes or no.)

 Yes

 No

109. Indicate how many community outreach/education sessions you hosted during this reporting period, if any. Do not include outreach or education sessions that are counted or reported in another section of this instrument.

110. Indicate the number of community organizations to whom you provided funding or other in-kind donations during this reporting period, if any:

(If none, proceed to question 112.)

111. How much funding did you provide to community organizations during this reporting period? (Include in-kind donations.)

112. Indicate the number of community organizations to whom you provided technical assistance during this reporting period, if any:

113. Did you reorganize local agencies to promote efficiency in delivering substance abuse prevention during this reporting period? (Select yes or no.)

 Yes

 No

114. Did you reallocate local funds for substance abuse prevention during this reporting period? (Select yes or no.)

 Yes

 No

115. Did you formally change ways local organizations work together to address substance abuse prevention during this reporting period, for example by officially changing school curricula or by documenting specific policies or practices for working together? (Select yes or no.)

 Yes

 No

116. Did you monitor regulatory or compliance changes by the state toward local or regional organizations during this reporting period? (Select yes or no.)

 Yes

 No

117. Did you conduct other community activities during this reporting period? (Select yes or no.)

 Yes (Describe.)

 No

118. How often did you conduct other community activities during this reporting period?

Use the table below to indicate the estimated percentages of each race that were targeted in the community-based processes component of this intervention during the reporting period.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American.

Racial Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify.)	____%	1.
		2.
		3.

Use the table below to indicate the estimated percentage of Hispanic/Latino populations that were targeted in the community-based processes component of this intervention during this reporting period and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Environmental Strategies Sub-Form

Throughout this section, “you” refers to your organization, or partners with your organization. For example, if you worked with the police department to conduct more sobriety checkpoints, you would report this activity on this form. Indicate the type(s) of environmental strategies (Web programming note: definition link) you worked to implement or implemented during this reporting period related to policy.

The questions below are an attempt to provide an exhaustive list of potential environmental strategies. SPF SIG community partners are not required to implement environmental strategies. The list below is meant to provide a standard way of reporting on environmental strategy implementation and activities. You will not be penalized if you indicate “no” as a response option. There is space at the end of this section to report on environmental strategies that are not listed here.

127. Did you work to enact open container laws prohibiting alcohol consumption in public places during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 129.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 129.)

128. Were you successful in your efforts to enact open container laws during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

129. Did you work to enact limits on the location, density (Web programming note: definition link), and hours of operation of liquor stores during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 131.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 131.)

130. Were you successful in your efforts to enact limits on the location, density (Web programming note: definition link), and hours of operation of liquor stores during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

131. Did you work to enact zoning ordinances to prohibit new alcohol outlets during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 133.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 133.)

132. Were you successful in your efforts to enact zoning ordinances during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

133. Did you work to enact limits on smoking in public places (e.g., movie theaters and restaurants) during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 135.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 135.)

134. Were you successful in your efforts to enact limits on smoking in public places during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

135. Did you work to enact limits on the use and placement of cigarette vending machines during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 137.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 137.)

136. Were you successful in your efforts to enact limits on the use and placement of cigarette vending machines during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

137. Did you work to enact regulations on alcohol or tobacco advertising and billboard placements in the community during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 139.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 139.)

138. Were you successful in your efforts to enact regulations on alcohol or tobacco advertising and billboard placements during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

139. Did you work to establish drug/alcohol/tobacco-free school zones and/or school use policies during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 141.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 141.)

140. Were you successful in your efforts to establish drug/alcohol/tobacco-free school zones and/or school use policies during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

141. Did you work to establish drug/alcohol/tobacco-free workplaces and/or workplace use policies during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 143.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 143.)

142. Were you successful in your efforts to establish drug/alcohol/tobacco-free workplaces and/or workplace use policies during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

143. Did you work to enact policies to reduce the problems/consequences associated with substance abuse (e.g., crime, driving under the influence, etc.) during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 145.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 145.)

144. Were you successful in your efforts to enact policies to reduce the problems/consequences associated with substance abuse during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

145. Did you work to implement organizational policies (e.g., within recreation leagues, summer camps, other non-governmental organizations) to reduce drug/alcohol/tobacco use among staff and youth during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 147.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 147.)

146. Were you successful in your efforts to implement organizational policies to reduce drug/alcohol/tobacco use among staff and youth during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

147. Did you work to implement keg registration (Web programming note: definition link) during this reporting period? (Select one response.)

 Yes

 No (If no, proceed to question 149.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 149.)

148. Were you successful in your efforts to implement keg registration (Web programming note: definition link) during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

149. Did you conduct other policy interventions (Web programming note: definition link) during this reporting period? (Select one response.)

 Yes (Describe.)________________________________________________

 No (If no, proceed to question 151.)

 Not applicable. This type of policy was in place prior to receipt of SPF SIG funding. (If not applicable, proceed to question 151.)

150. Were you successful in your efforts to conduct other policy interventions during this reporting period? (Select one response.)

 Yes

 We made some progress in this effort during this reporting period, but we still have some work to do.

 No

Indicate which of the following activities you conducted during this reporting period, in order to affect policy change.

151. Did you contact your representatives (e.g., to prohibit alcohol consumption and smoking in public places) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 154.)

152. How many representatives were contacted during this reporting period?

153. How many issues did you contact your representatives about during this reporting period?

154. Did you provide information to elected officials about policies to be enacted (e.g., to prohibit new alcohol outlets in the community) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 157.)

155. How many elected officials were provided information during this reporting period?

156. How many policies did you provide information on during this reporting period?

157. Did you organize a ballot initiative during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 159.)

158. How many ballot initiatives were organized during this reporting period?

159. Did you work with school administrators and teachers to implement a drug-free policy during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 161.)

160. How many schools did you engage in policy implementation during this reporting period?

161. Did you work with businesses to implement a drug-free workplace during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 163.)

162. How many businesses did you engage in policy implementation during this reporting period?

163. Did you conduct other policy activities during this reporting period? (Select yes or no.)

 Yes (Describe.)___________________________________________________

 No (If no, proceed to question 165.)

164. How often did you conduct other policy activities during this reporting period?

Indicate the type(s) of environmental strategies (Web programming note: definition link) you worked to implement or implemented during this reporting period related to enforcement.

165. Did you conduct compliance checks that target merchants who sell alcohol and tobacco to minors during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 168.)

166. How many compliance checks were conducted during this reporting period?

167. How many merchants were targeted during this reporting period?

168. Did you establish sobriety checkpoints during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 171.)

169. How many sobriety checkpoints were established during this reporting period?

170. Provide the frequency (Web programming note: definition link) of checkpoints during this reporting period.

171. Did you set up surveillance of areas known for illegal drug sales during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 173.)

172. How many areas were targeted for surveillance during this reporting period?

173. Provide the frequency Web programming note: definition link) of the surveillance during this reporting period.

174. Did you work to increase building inspections during this reporting period from the number of inspections conducted prior to this reporting period? (Select yes or no.)

 Yes

 No

175. Did you work to ensure that policies to force landlords to improve or demolish run-down buildings were enforced during this reporting period? (Select yes or no.)

 Yes

 No

176. Did you make use of civil and criminal "nuisance abatement" statutes, which require landlords to evict tenants involved in narcotics-related activities or risk personal prosecution during this reporting period? (Select yes or no.)

 Yes

 No

177. Did you enforce policies to reduce the problems/consequences associated with substance abuse during this reporting period? (Select yes or no.)

 Yes

 No

178. Did you conduct other enforcement activities during this reporting period? (Select yes or no.)

 Yes (Describe.) ___________________________________________________

 No (If no, proceed to question 180.)

179. How often did you conduct other enforcement activities during this reporting period?

Indicate which of the following activities you conducted during this reporting period in order to implement environmental strategies (Web programming note: definition link) related to enforcement: (Select all that apply.)

180. Did you educate law enforcement during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 183.)

181. How many law enforcement education sessions were conducted during this reporting period?

182. How many law enforcement officers were educated during this reporting period?

183. Did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community for sting operations, sobriety check-points, etc.) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 185.)

184. How many law enforcement officers were engaged in collaboration during this reporting period?

185. Did you conduct citizen patrols in neighborhoods known for illegal drug sales during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 188.)

186. How many citizen patrols were conducted during this reporting period?

187. How many neighborhoods known for illegal drug sales were patrolled during this reporting period?

188. Did you collaborate with municipal officials and private landlords to improve, rebuild, or raze abandoned buildings that are used to engage in drug use, adolescent alcohol use, and other illegal activities during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 191.)

189. How many municipal officials were engaged in collaboration during this reporting period?

190. How many private landlords were engaged in collaboration during this reporting period?

191. Did you conduct server training programs that work with bartenders and wait staff to reduce service to minors and intoxicated customers during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 194.)

192. How many server training programs were offered during this reporting period?

193. How many bartenders/wait staff were trained during this reporting period?

194. Did you educate merchants about the laws and penalties for selling to underage customers during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 197.)

195. How many merchant training programs were offered during this reporting period?

196. How many merchants were educated about the laws and penalties for selling to underage customers during this reporting period?

197. Did you conduct other enforcement activities during this reporting period? (Select yes or no.)

 Yes (Describe.)__________________________________________

 No (If no, proceed to question 199.)

198. How often did you conduct the other enforcement activities during this reporting period?

Indicate the type(s) of environmental strategies (Web programming note: definition link) you implemented during this reporting period related to communication.

199. Did you engage in social marketing during this reporting period? Social Marketing(Web programming note: definition link) is using the principles of commercial marketing to develop, implement, and evaluate programs designed to influence the behavior of a target audience. Rather than dictating the way that information is to be conveyed, social marketing involves listening to the needs and desires of the target audience and building the program from there. (Select yes or no.)

 Yes

 No (If no, proceed to question 210.)

200. How many social marketing campaigns were implemented during this reporting period?

201. How many television ads were created during this reporting period, as part of your social marketing campaigns?

202. How many television ads were aired during this reporting period, as part of your social marketing campaigns?

203. How many radio ads were created during this reporting period, as part of your social marketing campaigns?

204. How many radio ads were aired during this reporting period, as part of your social marketing campaigns?

205. How many print ads were created during this reporting period, as part of you social marketing campaigns?

206. How many print ads were published during this reporting period, as part of your social marketing campaigns?

207. How many special events (e.g., drug-free concert, smoke-free sponsored softball tournament) were hosted during this reporting period, as part of your social marketing campaigns?

208. How many other promotional activities (e.g., providing smoke-free pamphlets at a fair, distributing drug-free book covers at a school) were hosted during this reporting period as part of your social marketing campaigns?

209. How many promotional items were distributed during this reporting period, as part of your social marketing campaigns? Promotional items include pamphlets, brochures, leaflets, posters, videos or DVDs, and newsletters.

210. Did you engage in media literacy efforts during this reporting period? Media literacy programs foster the ability to analyze and evaluate messages in the media (e.g., working with children to teach them to evaluate the images and messages in a beer ad). (Select yes or no.)

 Yes

 No (If no, proceed to question 212.)

211. How many media literacy building sessions were held during this reporting period? A session is considered one class or gathering of participants. For example, if an intervention provides a class on tobacco ads and a class on alcohol ads, that would count as two sessions.

212. Did you conduct other communication interventions during this reporting period? (Select yes or no.)

 Yes (Describe.)_______________________________________________________

 No (If no, proceed to question 214.)

213. How often did you conduct other communication activities during this reporting period?

Indicate which of the following activities you conducted during this reporting period, in order to implement environmental strategies (Web programming note: definition link) related to communication.

214. Did you present at community meetings (e.g., PTA meetings, town meetings, school assemblies) during this reporting period? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select yes or no.)

 Yes

 No (If no, proceed to question 217.)

215. How many community meetings were presented at during this reporting period?

216. What was the total number of participants at all community meetings where you presented during this reporting period?

217. Did you send letters to the editor of the local newspaper or community newsletters during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 220.)

218. How many letters were sent during this reporting period?

219. How many letters were published during this reporting period?

220. Did community members gather to show disapproval of upcoming alcohol-sponsored events during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 222.)

221. How many of the gatherings protesting alcohol-sponsored events were held during this reporting period?

222. Did you develop substance abuse prevention public service announcements (PSAs) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 224.)

223. How many PSAs were developed during this reporting period?

224. Did you broadcast substance abuse prevention public service announcements (PSAs) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 226.)

225. How often were the PSAs broadcast during this reporting period?

226. Did you produce and/or distribute substance abuse prevention posters?

 Yes

 No (If no, proceed to question 229.)

227. How many posters were distributed?

228. How many weeks are the posters scheduled to be displayed?

weeks

229. Did you develop prevention-focused Web site(s) during this reporting period? (Select yes or no.)

 Yes

 No (If no, proceed to question 231.)

230. How many hits did the Web site(s) receive during this reporting period?

231. Did you conduct other communication activities during this reporting period? (Select yes or no.)

 Yes (Describe.)____________________________________________________

 No (If no, proceed to question 233.)

232. How often did you conduct other communication activities during this reporting period?

233. Describe any other type(s) of environmental strategies (Web programming note: definition link) you worked to implement or implemented during this reporting period that do not fall into the categories listed above.

(Provide a concise written description in the space available.)

234. What individuals or organizations did you work with in planning or implementing environmental strategies (Web programming note: definition link) during this reporting period? (Select all that apply.)

 Youth

 Parents

 Business community

 Media (e.g., radio and television stations, newspapers and magazines)

 School(s)

 Youth serving organization(s) (other than schools) (e.g., Big Brothers Big Sisters, Boy Scouts/Girl Scouts)

 Law enforcement agency/agencies

 Religious or fraternal organization(s) (e.g., churches, Lions Club, Kiwanis)

 Civic or volunteer organization(s) (e.g., local sports associations, neighborhood associations)

 Healthcare professionals

 State and/or local and/or tribal government agencies

 Other (Describe.)_____________________________________________________

235. When did you first start conducting environmental strategies as part of this intervention? (Provide MM/YYYY.)

MM/YYYY ____________

Use the table below to indicate the estimated percentages of each race that you targeted with the environmental strategies component of this intervention during the reporting period.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American.

Racial Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify.)	____%	1.
		2.
		3.

Use the table below to indicate the estimated percentage of Hispanic/Latino populations you targeted with the environmental strategies component of this intervention during the reporting period and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Information Dissemination Sub-Form

For this section, do not include activities or information that you have reported in other areas, such as the environmental strategies section.

244. What types of information did you disseminate? (Select all that apply.)

 Program information (e.g., contact information, meeting times, etc.)

 Substance abuse prevention information

 Surveillance and monitoring information, for example information about whom to contact if you suspect a meth lab is operating in your neighborhood.

 Drunk driving prevention information, such as free cab rides home on New Years Eve.

 Other (Describe.)________________________________________

245. What format was the information you disseminated? (Select all that apply.)

 Brochures

 Flyers

 Magnets

 Other promotional items (Frisbees, balls, cups)

 Other (Describe.)________________________________________

246. Describe the settings in which the information was disseminated. For example, the information may have been disseminated at a Parent Teacher Association meeting, a rock concert, a parade, etc.

___________________

247. Approximately how many individuals received the information disseminated?

___________________

248. What individuals or organizations did you work with in planning or implementing your information dissemination efforts Web programming note: definition link) during this reporting period? (Select all that apply.)

 Youth

 Parents

 Business community

 Media (e.g., radio and television stations, newspapers and magazines)

 School(s)

 Youth serving organization(s) (other than schools) (e.g., Big Brothers Big Sisters, Boy Scouts/Girl Scouts)

 Law enforcement agency/agencies

 Religious or fraternal organization(s) (e.g., churches, Lions Club, Kiwanis)

 Civic or volunteer organization(s) (e.g., local sports associations, neighborhood associations)

 Healthcare professionals

 State and/or local and/or tribal government agencies

 Other (Describe.)_____________________________________________________

249. When did you first start conducting information dissemination activities as part of this intervention? (Provide MM/YYYY.)

MM/YYYY _____________

Use the table below to indicate the estimated percentages of each race that you targeted with the information dissemination activities component of this intervention during the reporting period.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American.

Racial Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify.)	____%	1.
		2.
		3.

Use the table below to indicate the estimated percentage of Hispanic/Latino populations you targeted with the information dissemination activities component of this intervention and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of population targeted	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Other Activities or Services Delivered to Individuals Sub-Form

If your intervention included components delivered to individuals other than prevention education, alternative drug-free activities or problem identification and referral, use this form to provide information about this component. (Web programming note: After respondents complete one “Other Activities or Services Delivered to Individuals Sub-Form,” they will need to indicate whether they want to complete another “Other Activities or Services Delivered to Individuals Sub-Form.”)

258. Describe any other component of the intervention that was delivered to individuals.

259. When did you first start conducting this component of the intervention? (Provide MM/YYYY.)

MM/YYYY

260. What was the average duration of one session during this reporting period?

hours

261. How many sessions did you conduct during this reporting period?

262. What was the format of this component during this reporting period? (Select all that apply.)

 Individual

 Small group (2-9)

 Large group (10-49)

 Extra large group (50+)

 Web-based

 Other (Describe.)

263. Indicate the types of participants served by this component during this reporting period. (Select all that apply.)

 Children age 0 to 3

 Children age 4 to 5

 Children age 6 to 11

 Youth age 12 to 17

 Young adults age 18 to 20

 Young adults age 21 to 24

 Parents

 Adults 18 and over, but not parents

 Community leaders

 Healthcare providers

 Substance abuse prevention/treatment workers

 Law enforcement

 Other (Describe.) ________________________________________________

264. As delivered, how would you classify this other intervention component according to the Institute of Medicine categories? (Select one response.)

 Universal (Web programming note: definition link)

 Selective (Web programming note: definition link)

 Indicated (Web programming note: definition link)

Use the table below to indicate the percentage (or to estimate the percentage) of participants served by your other component of each race during the reporting period.

If you do not know exact percentages, you may estimate percentages using community/school profiles or community census data. Note: If information on race was not collected for Hispanic populations, include this population as “other” on the race category.

You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) row and the race row under African American.

Racial Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Korean, Apache Indian Tribe)
American Indian/Alaska Native	____%	1.
		2.
		3.
Asian	____%	1.
		2.
		3.
Black or African American	____%	1.
		2.
		3.
Native Hawaiian or Other Pacific Islander	____%	1.
		2.
		3.
White	____%	1.
		2.
		3.
Participants who selected more than one race	____%	1.
		2.
		3.
Other (Specify)	____%	1.
		2.
		3.

Use the table below to indicate the percentage of your population served during this reporting period that considered themselves of Hispanic or Latino background and list any specific subpopulations that were targeted.

Ethnic Category	a. Percentage of participants served	b. Subgroups targeted, if applicable (e.g., Puerto Rican)
Hispanic/Latino	____%	1.
		2.
		3.

Other Activities or Services Not Delivered to Individuals Sub-Form

If you used a component other than community-based processes, environmental strategies, or information dissemination to implement your intervention that did not involve specific participants, use this form to provide information about this component. (Web programming note: After respondents complete one “Other Activities or Services Not Delivered to Individuals Sub-Form,” they will need to indicate whether they want to complete another “Other Activities or Services Not Delivered to Individuals Sub-Form.”)

273. Describe the activities or services you provided that were not delivered to individuals. Make sure to include reports of any counts or frequencies, as they apply.

274. Describe the intended target population for these activities or services.

275. When did you first start conducting these other non-participant based activities, as a component of this intervention? (Provide MM/YYYY.)

MM/YYYY

Burden Statement: Public reporting burden of this collection of information is estimated to average XX hours per response.  Send all comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, Choke Cherry Road, Rockville, MD 20857.  An agency may not sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  The control number for this project is XXXX-XXXX.

APPENDIX C

Screen Shots of Web-based Community-level Instrument (Part I and II)

(See attached HTML zip file)

APPENDIX D

Members of the SPF SIG External Technical Advisory Group

SPF SIG NATIONAL EVALUATION EXTERNAL TECHNICAL ADVISORY GROUP

Greg Bloss

Head of Health Policy Research Division

301-443-3865

gbloss@mail.nih.gov

National Institute on Alcohol Abuse

& Alcoholism

5635 Fishers Lane, MSC 9304

Bethesda, MD 20892-9304

301.443.1274 (w)

rhingson@mail.nih.gov

Dorothy Browne, Ph.D., Director

Prevention Sciences Research Center/Drug

Abuse Program

Morgan State University

Baltimore, MD 21251

443.885.4533 (w)

dbrowne@morgan.edu

Richard Catalano, Ph.D.

SDRG

University of Washington

Box 359106

Seattle, WA 98195

206-543-6382

catalano@u.washington.edu

Richard Cervantes, Ph.D.

Research Director

Behavioral Assessment, Inc.

291 S. La Cienega, Suite 308

Beverly Hills, CA 90211

310.652.6449

bassessment@aol.com

Linda Dusenbury

Tanglewood Research

148 Longleaf Road

Southern Pines, NC 28387

910-692-8412

lindadusenbury@tanglewood.net

Dennis Embry

P.O. PAXIS Institute, P.O. 684984

Tucson, AZ 85737

520-299-6770

520-299-6822 (Fax)

dde@paxis.org

Susan Ennett

University of North Carolina at Chapel Hill

Health Behavior and Health Education

CB #7440, 311 Rosenau Hall

Chapel Hill, NC 27599

919-966-9207

sennett@email.unc.edu

Vivian Faden (Deputy Director)

301-594-6232

vfaden@mail.nih.gov

Steve Fawcett

University of Kansas,

1000 Sunnyside Ave.,

Dole Human Development Center,

Room 4058

Lawrence, KS 66045-7555

785 864 0533

913-864-5281 (Fax)

sfawcett@ku.edu

Larry Green, Ph.D.

Centers for Disease Control & Prevention (CDC)

Office of Science & Extramural Research

Public Health Practice Program Office

4770 Buford Highway NE, Mailstop K56

Atlanta, GA 30341

770.488.8474

Wayne Harding, Ph.D.

Social Science Research and Evaluation, Inc.

21-C Cambridge Street

Burlington, MA 01803

781-273-4206

wayneh@gis.net

wharding@ssre.org

Pamela S. Imm

Community Psychologist

200 Buckthorne Drive

Lexington, SC 29072

803-733-1390 x137

803-733-1395

pamimm@alltel.net; pimm@lradac.org

James Jackson, Ph.D.

Director and Research Professor

Institute for Social Research

Daniel Katz Distinguished University

Professor of Psychology

University of Michigan

Ann Arbor, MI

734-763-2491

jamessj@umich.edu

Jerry Jaker

Minnesota Institute of Public Health

Central CAPT

2720 Highway 10

Mounds View, MN 55122

763-427-5310

gjaker@miph.org

Sandeep Kasat, Ph.D.

Epidemiologist

Office of Substance Abuse

11 State House Station

Augusta, ME 04333

207-287-4372

sandeep.kasat@maine.gov

Don Maestas

Bureau Chief

NM Dept. of Health

Behavioral Health Services Division

1190 St. Francis Dr.

Santa Fe, NM 87502

505-827-2652

Donald.maestas@state.nm.us

Mary Ann Pentz

University of Southern California

Institute for Prevention Research

Alhambra, CA 91803

626-457-6691

pentz@usc.edu

Home:

110 La Brea St.

Laguna Beach, CA 92651

(949-494-7409)

Janice Petersen, Ph.D., Director

North Carolina Office of Prevention

301 W. Jones St., Suite 250

3021 MSC

Raleigh, NC 27699-

919.715.5989

janice.petersen@ncmail.net

Deborah J. Rog, Ph.D.

Vanderbilt Institute for Public Policy Studies

Center for Mental Health Policy

1915 I St. NW, Suite 600

Washington, DC 20006

202.833.3512 (w)

debra.j.rog@vanderbilt.edu

Gilbert Saint-Jean, MD, MPH, PhD

Associate Scientist

Department of Epidemiology and Public Health

University of Miami School of Medicine

1801 NW 9th Ave Room # 212C

Miami, FL 33136

Phone: 305-243-6571

Fax: 305-243-6436

GSaint@med.miami.edu

Mary VanderWall

Director, Prevention Services

CO Dept. of Human Services

Alcohol and Drug Abuse Division

4055 S. Lowell Blvd.

Denver, CO 80236

303-866-7480 x7503

Mary.vanderwall@state.co.us

Linda Vasquez

DREAM of Hattiesburg, Inc.

200 West Pine (basement)

Hattiesburg, MS 39401

601-545-2102

601-543-9961 (work cell)

601-543-9243 (Cell)

vblmv@comcast.net

Beth Welbes

Senior Coordinator of Research

University of Illinois

Center for Prevention Research and Development

510 Devonshire Dr.

Champaign, IL  61820

217/333-3796 phone

217/244-0214 fax

echamb@uiuc.edu

Chris Williams, Ph.D., Director,

Strategic Partnerships & Government Affairs

National Health Promotion Associates, Inc.

711 Westchester Ave.

White Plains, NY 10604

914.421.2525

cwilliams@nhpanet.com

SAMHSA/CSAP/NIDA PARTICIPANTS

Beverly Watts Davis

CSAP Director

Office of the Director

1 Choke Cherry Rd., 4-1056

Rockville, MD 20850

Phone: 240-276-2420

Email: beverly.wattsdavis@samhsa.hhs.gov

Wilson Compton

Director

Division of Epidemiology, Services and Prevention Research

National Institute on Drug Abuse

National Institutes of Health

U.S. Department of Health and Human Services

6001 Executive Boulevard

Room 6001

Bethesda, MD 20892-9589

Phone: 301-443-6504

Augie Diana

Task Order Officer, SPF SIG Cross-site Evaluation

Division of State and Community Assistance

1 Choke Cherry Rd., 4-1081

Rockville, MD 20850

Phone: 240-276-2559

Email: augusto.diana@samhsa.hhs.gov

Wil Hardy

Task Order Officer, SPF SIG Cross-site Evaluation

Division of State and Community Assistance

1 Choke Cherry Rd., 4-1087

Phone: 240-276-2404

Email: thomas.deloe@samhsa.hhs.gov

Elizabeth (Liz) Robertson

Chief , Prevention Research Branch

Division of Epidemiology, Services and Prevention Research

National Institute on Drug Abuse

National Institutes of Health

U.S. Department of Health and Human Services

6001 Executive Boulevard

Room 5153

Bethesda, MD 20892-9589

Phone: 301-443-6504

Email: er52h@nih.gov

Mike Lowther

Division Director

Division of State and Community Assistance

1 Choke Cherry Rd., 4-1093

Rockville, MD 20850

Phone: 240-276-2581

Email: mike.lowther@samhsa.hhs.gov

Kevin P. Mulvey, PhD

Chief, Practice Assessment and

Applications Branch

SAMHSA/CSAP/DKASI

1 Choke Cherry Rd 4-1019

Rockville, MD 20857

Ph: 240-276-2971

Fax:240-276-2410

APPENDIX E

Members of the SPF SIG Internal Workgroup

IWG Members

CSAP

Augie Diana

Task Order Officer, SPF SIG Cross-site Evaluation

Division of State and Community Assistance

1 Choke Cherry Rd., 4-1081

Rockville, MD 20850

Phone: 240-276-2559

Email: augusto.diana@samhsa.hhs.gov

Wil Hardy

Task Order Officer, SPF SIG Cross-site Evaluation

Division of State and Community Assistance

1 Choke Cherry Rd., 4-1087

Rockville, MD 20850

Phone: 240-276-2561

Email: wilbert.hardy@samhsa.hhs.gov

Mike Lowther

Division Director

Division of State and Community Assistance

1 Choke Cherry Rd., 4-1093

Rockville, MD 20850

Phone: 240-276-2581

Email: mike.lowther@samhsa.hhs.gov

Kevin P. Mulvey, PhD

Chief, Practice Assessment and

Applications Branch

SAMHSA/CSAP/DKASI

1 Choke Cherry Rd 4-1019

Rockville, MD 20857

Ph: 240-276-2971

Fax:240-276-2410

Kevin D. Hennessy, Ph.D.

Science to Service Coordinator

Office of Policy, Program and Budget

Substance Abuse an Mental Health Services Administration (SAMHSA)

1 Choke Cherry Road, Room 8-1017

Rockville, MD 20857

Phone: (240) 276-2234

Fax: (240) 276-1024

Email: kevin.hennessy@samhsa.hhs.gov

NIDA

Wilson Compton

Director

Division of Epidemiology, Services and Prevention Research

National Institute on Drug Abuse

National Institutes of Health

U.S. Department of Health and Human Services

6001 Executive Boulevard

Room 6001

Bethesda, MD 20892-9589

Phone: 301-443-6504

Email: wcompton@nida.nih.gov

Elizabeth (Liz) Robertson

Chief

Prevention Research Branch

Division of Epidemiology, Services and Prevention Research

National Institute on Drug Abuse

National Institutes of Health

U.S. Department of Health and Human Services

6001 Executive Boulevard

Room 5153

Bethesda, MD 20892-9589

Phone: 301-443-6504

Email: er52h@nih.gov

Westat

Rob Orwin

Project Director

Westat

1650 Research Blvd.; RA 1408

Rockville, MD 20874

Phone: 301-251-2277

Email: RobertOrwin@westat.com

Ann Landy

Associate Director

Westat

1650 Research Blvd.; TB 172

Rockville, MD 20874

Phone: 301-251-2219

Email: AnnLandy@westat.com

Joseph Sonnefeld

Senior Study Director

Westat

1650 Research Blvd.; TB 172

Rockville, MD 20874

Phone: 240-214-2522

Email: JosephSonnefeld@westat.com

Sarah Barrett

Project Coordinator

Westat

1650 Research Blvd.; TB 162

Rockville, MD 20874

Phone: 301-294-2044

Email: SarahBarrett@westat.com

Mayatech Associates

Kristi Pettibone

Health Policy Analyst

The MayaTech Corporation

1100 Wayne Ave., Suite 900

Silver Spring, MD 20910

Phone: 301-587-1600

Email: KPettibone@MayaTech.com

PIRE

Doug Piper

Madison Center Director

Senior Research Scientist

Pacific Institute for Research & Evaluation – Madison Center

437 S. Yellowstone Dr., Suite 201

Madison, WI 53719

Phone: 608-819-0109x12

Email: piper@pire.org

Bob Flewelling
Senior Research Scientist
Pacific Institute for Research and Evaluation
1516 East Franklin St. Suite 200
Chapel Hill, NC 27514-3307
Phone: 919-265-2621
Fax: 919-265-2659
Email: flewelling@pire.org

Alan D. Stein-Seroussi, Ph. D.

Senior Research Scientist

109 Creekview Circle

Carrboro, NC 27510

Phone: 919-967-8998

Email: stein@pire.org

1037601 1