Form Tab B - Guidance A Tab B - Guidance A Tab B - Guidance Application

OMB No. 0930-0080

FINAL

UNIFORM APPLICATION

FY 2011

SUBSTANCE ABUSE PREVENTION AND TREATMENT

BLOCK GRANT

42 U.S.C. §300x-21 through §300x-66

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Center for Substance Abuse Prevention

Page Intentionally Left Blank

INTRODUCTION

The Substance Abuse Prevention and Treatment Block Grant represents a significant Federal contribution to the States’ substance abuse prevention and treatment service budgets. The Public Health Service Act [42 U.S.C. §§300x-21-66] authorizes the Substance Abuse Prevention and Treatment Block Grant and specifies requirements attached to the use of these funds. The SAPT Block Grant funds are annually authorized under separate appropriation by Congress. The Public Health Service Act designates the Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention as the entities responsible for administering the SAPT Block Grant program.

The SAPT Block Grant application format provides the means for States to comply with the reporting provisions of the Public Health Service Act (42 U.S.C. §§300x-21-66), as implemented by the Interim Final Rule (45 C.F.R. Part 96, part XI). With regard to the requirements for Goal 8, the Annual Synar Report format provides the means for States to comply with the reporting provisions of the Synar Amendment (Section 1926 of the Public Health Service Act), as implemented by the Tobacco Regulation for the SAPT Block Grant (45 C.F.R. Part 96, part IV).

Public reporting burden for this collection of information is estimated to average 454 hours per respondent for Sections I-III, 40 hours per respondent for Section IV-A and 42.75 hours per respondent for Section IV-B, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (OMB No. 0930-0080), 1 Choke Cherry Road, Room 7-1042, Rockville, Maryland 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is OMB No. 0930-0080.

The Web Block Grant Application System (Web BGAS) has been developed to facilitate States’ completion, submission and revision of their Block Grant application. The Web BGAS can be accessed via the World Wide Web at http://bgas.samhsa.gov.

How the application helps the Substance Abuse and Mental Health Services Administration

Part of the mission of the Center for Substance Abuse Treatment (CSAT) and the Center for Substance Abuse Prevention (CSAP) is to assist States¹ and communities to improve activities and services provided with funds from the Substance Abuse Prevention and Treatment (SAPT) Block Grant. One strategy CSAT and CSAP are using to promote increased State accountability for the management of Block Grant funds is the uniform application. In accordance with the Block Grant regulations, the States are asked to provide detailed data on expenditures of the FY 2008 SAPT Block Grant award (and intended use of the FY 2011 SAPT Block Grant award) and from other Federal, State and local government funds. Another strategy is CSAT’s State Systems Development Program and CSAP’s Strategic Prevention Framework Advancement and Support Project, which are enhanced technical assistance programs involving conferences and workshops, development of training materials and knowledge transfer manuals, and on-site consultation.

How the application can help States

The information gathered for the application can help States describe and analyze sub-State needs, and plan strategies to address gaps in service. The data can also be used to report to the State legislature and other State and local organizations. Aggregated statistical data from States’ applications can demonstrate to Congress the magnitude of the national substance abuse problem and the effectiveness of Federal-State resources targeted to serve individuals, families, and communities impacted by substance use disorders. This information will also provide Congress with a better understanding of funding needs.

Where and when to submit the application

Submit one signed original of the Assurances and Certifications by October 1, 2010 to:

Barbara Orlando, M.S., Grants Management Specialist

Formula Grant Team

Substance Abuse and Mental Health Services Administration

Office of Program Services

Division of Grants Management

Regular Mail Overnight mail:

1 Choke Cherry Road, Room 7-1091 (240) 276-1422

Rockville, Maryland 20857 1 Choke Cherry Road, Room 7-1091

Rockville, Maryland 20850

Overview of the application

The application has four sections. It covers the SAPT Block Grant for the prevention and treatment of substance abuse. All sections require the completion of standard forms.

Section	Contents	Forms	Pages
Section I	Identifying information, Table of Contents, and Funding Agreements/Certifications	Forms 1, 2, 3	5-22
Section II	State Plan – Intended use of FY 2011-13 SAPT Block Grant Funds	Forms 4, 5, 6, 6a, 6b, 6c and 7 Tables I through IV	23-43
Section III	Annual Report – Actual use of FY 2008 SAPT Block Grant Funds. Narrative: FY 2008 Annual Report, FY 2010 Progress Report, FY 2011-2013 Intended Use. Attachments – Special requirements and waivers	Forms 8, 9, 10	44-93
Section IVa	Treatment Performance Measures	Forms T1-T7	94-124
Section IVb	Prevention Performance Measures	Forms P1-P15	125-171

The application is submitted to SAMHSA using Web BGAS; therefore, a State need only print out three Certifications/Assurances (Form 3), Assurances-Non-Construction Programs, and Certifications, sign and mail them early enough to arrive at SAMHSA by October 1, 2010. The Disclosure of Lobbying Activities form must also be signed, if applicable.

A MS Word copy of the uniform application and forms is available on CSAT’s Treatment Improvement Exchange Website. To download the application, go to:

http://www.tie.samhsa.gov/sapt2011-13.html

Footnotes

The Web BGAS features a footnote button that allows States to enter additional information, as appropriate.

What to do if your State cannot complete all items in Sections I-IV

If your State does not have reliable data to complete an item on the application, or if you cannot get sufficient information to respond fully by the due date, do not leave the item blank. Instead, use one of these options:

Provide a clear explanation of your problem in obtaining the data.

Describe the alternative method of data collection you use.

Explain how you carry out the activity.

Indicate when complete information will be available.

Whenever you have a problem completing an item, describe what kind of financial or technical assistance you would need to improve your response in future years.

Getting assistance in completing the application

If you have questions about programmatic issues, you may call CSAT’s Division of State and Community Assistance, Performance Partnership Grant Branch at (240) 276-2890 or CSAP’s Division of State Programs at (240) 276-2550 and ask for your respective State project officer or contact the State project officer directly by telephone or Internet e-mail using the directory provided (See Appendix A). If you have questions about Web-BGAS, call 888-301-BGAS. If you have questions about fiscal or grants management issues, you may call Barbara Orlando, M.S., Grants Management Specialist, Formula Grant Team, Office of Program Services, Division of Grants Management, at (240) 276-1422 or barbara.orlando@samhsa.hhs.gov.

SECTION I: IDENTIFYING INFORMATION AND ASSURANCES

This section of the application has three items:

1. Face Page (Form 1)

2. Table of Contents (Form 2)

3. Funding Agreements/Certifications (Form 3)

Assurances-Non-Construction Programs

Certifications

1. Face Page (Form 1)

This form is pre-numbered as page 3 in Web BGAS. It requires the entry of identifying information and is self-explanatory. However, please take special note of the following:

• Item I, State Agency to be the Grantee for the Block Grant, requires both the name of the responsible agency designated by the Governor as the official grantee and the name of the organizational unit within that agency that administers the block grant.

• Item II, Contact Person for the Grantee of the Block Grant, requires identifying the person with overall responsibility for the block grant and providing contact information, including e-mail address.

• Item III, State Expenditure Period, is the most recent 12-month State expenditure period for which expenditure information is complete. This is probably the most recent State fiscal year that is closed out. When you submit your annual and progress reports next year for the FY 2012 award, your State expenditure period will be the next consecutive 12-month period.

• Item IV, Date Submitted, is the calendar date on which the uniform block grant application is first submitted to SAMHSA.

• Item V, Contact Person Responsible for Application Submission, is the name of the individual to whom SAMHSA should address comments and/or questions concerning the content of the uniform block grant application.

Uniform Application for FYs 2011-13 Substance Abuse Prevention and Treatment Block Grant
State Name:		DUNS Number:
I. State Agency to be the Grantee for the Block Grant
Agency Name:
Organization Unit:
Mailing Address:
City:	Zip Code:
II. Contact Person for the Grantee of the Block Grant
Name:
Agency Name:
Mailing Address:
City: 	Zip Code:
Telephone: 	Facsimile:
E-Mail:
III. State Expenditure Period (Most recent State expenditure period that is closed out)
From:	To:
IV. Date Submitted
Date:	Original: Revision:
V. Contact Person Responsible for Application Submission
Name:	Telephone:
E-Mail:	Facsimile:

Form 1

2. Table of Contents (Form 2)

The Table of Contents (Form 2) in Web BGAS is a reference checklist that will help you see all the required Forms and checklists and those which have at least some data entered on them. Once all items listed on Form 2 are complete, a State need only read, print, sign, and mail Form 3, Assurances-Non-Construction Programs, and Certifications to complete their application.

Form 2: FY 2011 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents
Item number	Form Description		Page
I. Introduction, Identifying Information and Assurances
1	Introduction		1-4
2	Face Page: Uniform Application for FY 2011 Substance Abuse Prevention and Treatment Block Grant (Form 1)		5-6
3	Table of Contents (Form 2)		7-11
4	Funding Agreements/Certifications		12
		I. Chief Executive Officer’s Funding Agreements/Certifications (Form 3)	13-14
		II. Certifications	15-17
		III. Disclosure of Lobbying Activity	18-20
		IV. Assurances-Non-Construction Programs	21-22
II. State Plan – Intended Use of FY 2011-2013 Substance Abuse Prevention and Treatment Block Grant Funds
1	Planning (narrative)		23-25
2	Criteria for allocating funds (checklist)		25-26
3	Treatment Needs Assessment Summary Matrix (Form 4)		26-28
4	Treatment needs by age, sex, and race/ethnicity (Form 5)		29-30
5	How Your State Determined the Form 4 and 5 Estimates		31
6	Annual Intended Use Plan (Form 6)		31-33
7-8	Primary Prevention Planned Expenditure Checklist (Form 6a and 6b)		34-38
9	Resource Development Planned Expenditure Checklist (Form 6c)		39
10	Purchasing Services; Methods for purchasing (checklist)		40
	Table of Contents continues on following pages

Form 2: FYs 2011-2013 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description	Page
11	Purchasing Services; Methods for determining prices (checklist)	41
12	Program Performance Monitoring (checklist)	42
13	State Priorities (Form 7)	43
III. Annual Report, Progress Report and State Plan in regards to Federal Requirements
1	Report on the Federal Requirements: FY 2008 Annual Report; FY 2010 Progress Report; FY 2011-13 Intended Use Plan (narrative)	44-46
2	Goal 1: The State shall expend block grant funds to maintain a continuum of substance abuse treatment services that meet these needs for the services identified by the State.	47
3	Goal 2: An agreement to spend no less than 20 percent on primary prevention programs for individuals who do not require treatment for substance abuse, specifying the activities proposed for each of the six strategies. Additional instructions: Prevention (checklist)	47-49
4	Goal 3: An agreement to expend not less than an amount equal to the amount expended by the State for FY 1994 to establish new programs or expand the capacity of existing programs to make available treatment services designed for pregnant women and women with dependent children; and, directly or through arrangements with other public or nonprofit entities, to make available prenatal care to women receiving such treatment services, and, while the women are receiving services, child care. Additional instructions: Programs for Pregnant Women and Women with Dependent Children	49-50
5	Goal 4: An agreement to provide treatment to intravenous drug abusers that fulfills the 90 percent capacity reporting, 14-120 day performance requirement, interim services, outreach activities and monitoring requirements. Additional instructions: Programs for Intravenous Drug Users (IVDUs) and Program Compliance Monitoring	50-51
6	Goal 5: An agreement, directly or through arrangements with other public or nonprofit private entities, to routinely make available tuberculosis services to each individual receiving treatment for substance abuse and to monitor such service delivery.	52
7	Goal 6: An agreement, by designated States, to provide treatment for persons with substance abuse problems with an emphasis on making available within existing programs early intervention services for HIV in areas of the State that have the greatest need for such services and to monitor such service delivery. Additional instructions: Tuberculosis (TB) and Early Intervention Services for HIV	52-53
8	Goal 7: An agreement to continue to provide for and encourage the development of group homes for recovering substance abusers through the operation of a revolving loan fund. Additional instructions: Group Home Entities and Programs	53-54
9	Goal 8: An agreement to continue to have in effect a State law that makes it unlawful for any manufacturer, retailer, or distributor of tobacco products to sell or distribute any such product to any individual under the age of 18; and, to enforce such laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under age 18.	54
	Table of Contents continues on following pages
Form 2: FYs 2011-2013 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description	Page
10	Goal 9: An agreement to ensure that each pregnant woman be given preference in admission to treatment facilities; and, when the facility has insufficient capacity, to ensure that the pregnant woman be referred to the State, which will refer the woman to a facility that does have capacity to admit the woman, or if no such facility has the capacity to admit the woman, will make available interim services within 48 hours, including a referral for prenatal care. Additional instructions: Capacity Management and Waiting List Systems	54-55
11	Goal 10: An agreement to improve the process in the State for referring individuals to the treatment modality that is most appropriate for the individual.	55-56
12	Goal 11: An agreement to provide continuing education for the employees of facilities which provide prevention activities or treatment services.	56
13	Goal 12: An agreement to coordinate prevention activities and treatment services with the provision of other appropriate services.	56
14	Goal 13: An agreement to submit an assessment of the need for both treatment and prevention in the State for authorized activities, both by locality and by the State in general.	57
15	Goal 14: An agreement to ensure that no program funded through the block grant will use funds to provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs.	57
16	Goal 15: An agreement to assess and improve, through independent peer review, the quality and appropriateness of treatment services delivered by providers that receive funds from the block grant. Additional instructions: Independent Peer Review	57-58
17	Goal 16: An agreement to ensure that the State has in effect a system to protect patient records from inappropriate disclosure.	58
18	Goal 17: An agreement to ensure that the State has in effect a system to comply with 42 U.S.C. §300x-65 and 42 C.F. R. part 54.	59
19	Additional instructions: Charitable Choice	59-60
20	Additional instructions: Waivers	60-61
21	Substance Abuse State Agency Spending Report (Form 8)	62-65
22	Primary Prevention Expenditures Checklist (Form 8a and 8b)	66-68
23	Resource Development Expenditures Checklist (Form 8c)	69-70
24	Substance Abuse Entity Inventory (Form 9)	71-75
25	Prevention Strategy Report Risk Strategies (Form 9a)	76-79
26	Treatment Utilization Matrix (Form 10a)	80-83
	Table of Contents continues on following pages

Form 2: FYs 2011-2013 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description	Page
27	Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services (Form 10b)	84-85
28	Description of Calculations	86
29. I-IV.	Maintenance of Effort (MOE) Tables: (Single State Agency [SSA] MOE, TB MOE, HIV MOE, and Women’s Base). (Tables I-IV)	86-93
IVa. TREATMENT PERORMANCE MEASURES AND SUMMARY NARRATIVE
	Instructions and Summary Narrative Description	96-98
1	Form T1-Employment\Education Status (from Admission to Discharge)	99-103
2	Form T2- Stability of Housing: Living Status (from Admission to Discharge)	104-106
3	Form T3-Criminal Justice Involvement (from Admission to Discharge)	107-110
4	Form T4-Change in Abstinence: Alcohol Use (from Admission to Discharge)	111-114
5	Form T5-Change in Abstinence: Other Drug Use (from Admission to Discharge)	115-118
6	Form T6-Change in Social Support of Recovery (from Admission to Discharge)	119-122
7	Form T7-Retention: Length of Stay (in Days) of Clients Completing Treatment	123-124
IV b. PREVENTION PERFORMANCE MEASURES
1	Form P1-NOMs Domain: Reduced Morbidity - Measure: 30 Day Use	131-132
2	Form P2-NOMs Domain: Reduced Morbidity - Measure: Perception of Risk/Harm of Use	133
3	Form P3-NOMs Domain: Reduced Morbidity - Measure: Age of First Use	134
4	Form P4-NOMs Domain: Reduced Morbidity - Measure: Perception of Disapproval/Attitudes	135
5	Form P5-NOMs Domain: Employment/Education - Measure: Perception of Workplace Policy	136
6	Form P6-NOMs Domain: Employment/Education - Measure: ATOD-Related Suspensions and Expulsions (In Development)	136
7	Form P7-NOMs Domain: Employment/Education - Measure: Average Daily School Attendance Rate	136
8	Form P8- NOMs Domain: Crime and Criminal Justice - Measure: Alcohol-Related Traffic Fatalities	137
	Table of Contents continues on following pages

Form 2: FYs 2011-2013 Uniform Application for the Substance Abuse Prevention and Treatment Block Grant Table of Contents (continued)
Item number	Form Description	Page
IV b. PREVENTION PERFORMANCE MEASURES
9	Form P9-NOMs Domain: Crime and Criminal Justice - Measure: Alcohol- and Drug-Related Arrests	137
10	Form P10-NOMs Domain: Social Connectedness - Measure: Family Communications Around Drug and Alcohol Use	138
11	Form P11-NOMs Domain: Retention - Measure: Youth Seeing, Reading, Watching, or Listening to a Prevention Message	138
12	Form P12a and 12b-Number of Persons Served by Age, Gender, Race, and Ethnicity - NOMs Domain: Access/Capacity - Measure: Persons Served by Age, Gender, Race, and Ethnicity	140-146
13	Form P13-(Optional) Persons Served by Type of Intervention - NOMs Domain: Access/Capacity—Measure: Persons Served by Type of Intervention	147-150
14	Form P14-Evidence-Based Programs and Strategies by Type of Intervention - NOMs Domain: Retention - NOMs Domain: Use of Evidence-Based Programs - Measure: Evidence-Based Programs and Strategies	151-153
15	Form P15-Relative Cost of Evidence-Based Programs/Strategies – (EBPs) NOMs Domain: Cost Effectiveness - Measure: Percentage of Total Prevention Costs Expended on Evidence-Based Programs/Strategies	154
	Prevention Attachment A: Application Form to Substitute Data	156-163
	Prevention Attachment B: Substitution Appeal Form	164-165
	Prevention Attachment C: Approved Data Submission Form	166
	Prevention Attachment D: Optional 2008 Block Grant Relative Cost Worksheet	167-169
	Attachment A: Goal 2	170-172
	List of Forms	173-174
	Appendix A─ State Project Officer Directory Center for Substance Abuse Treatment Center for Substance Abuse Prevention	175 177-179 180-182
	Appendix B─ FY 2011 Allocation Table for SAPT Block Grant and List of HIV “Designated States”	185-189

3. Funding Agreements/Certifications

The following three standard forms (I, II, and IV) must be signed by the Chief Executive Officer or an authorized designee and submitted with this application. The Disclosure of Lobbying Activity form must be signed, if applicable. Current documentation authorizing a designee must be on file with SAMHSA. Any change in the Chief Executive Officer of the State or the position or person to whom such delegation has been authorized will require new documentation.

I. Chief Executive Officer’s Funding Agreements/Certifications (Form 3)

II. Certifications

Certifications 1-5 are included on OMB approved form, OMB approval # 0920-0428 which requires one signature.

1. Certification Regarding Debarment and Suspension

2. Certification Regarding Drug-Free Workplace Requirements

This certification is included in the application package. It has to be submitted only if a Statewide or agency-wide annual assurance has not been submitted to DHHS.

3. Certifications Regarding Lobbying

This certification, included in the application package, must be signed and submitted before the award of any Federal grant or cooperative agreement exceeding $100,000.

4. Certification Regarding Program Fraud Civil Remedies Act (PFCRA)

5. Certification Regarding Environmental Tobacco Smoke

III. Disclosure of Lobbying Activities

Standard Form LLL and LLL-A need to be signed and completed only if the grantee has undertaken any lobbying during the 12 month State expenditure period designated on Form 1.

Completion of Form SF-LLL is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate.

IV. Assurances-Non-Construction Programs

Form 3: Uniform Application for FY 2011 Substance Abuse Prevention and Treatment Block Grant

Funding Agreements/Certifications

as required by Title XIX, Part B, Subpart II and Subpart III of the Public Health Service (PHS) Act

As part of the annual application for Block Grant funds, it is required under Title XIX, Part B, Subpart II of the Public Health Services Ac Title XIX, Part B, Subpart II and Subpart III of the PHS Act, as amended, requires the chief executive officer (or an authorized designee) of the applicant organization to certify that the State will comply with the following specific citations as summarized and set forth below, and with any regulations or guidelines issued in conjunction with this Subpart except as exempt by statute.

SAMHSA will accept a signature on this form as certification of agreement to comply with the cited provisions of the PHS Act. If signed by a designee, a copy of the designation must be attached.

I. Formula Grants to States, Section 1921

Grant funds will be expended “only for the purpose of planning, carrying out, and evaluating activities to prevent and treat substance abuse and for related activities” as authorized.

II. Certain Allocations, Section 1922

• Allocations Regarding Primary Prevention Programs, Section 1922(a)

• Allocations Regarding Women, Section 1922(b)

III. Intravenous Drug Abuse, Section 1923

• Capacity of Treatment Programs, Section 1923(a)

• Outreach Regarding Intravenous Substance Abuse, Section 1923(b)

IV. Requirements Regarding Tuberculosis and Human Immunodeficiency Virus, Section 1924

V. Group Homes for Recovering Substance Abusers, Section 1925

Optional beginning FY 2001 and subsequent fiscal years. Territories as described in Section 1925(c) are exempt.

The State “has established, and is providing for the ongoing operation of a revolving fund” in accordance with Section 1925 of the PHS Act, as amended. This requirement is now optional.

VI. State Law Regarding Sale of Tobacco Products to Individuals Under Age of 18, Section 1926

• The State has a law in effect making it illegal to sell or distribute tobacco products to minors as provided in Section 1926 (a)(1).

• The State will enforce such law in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under the age of 18 as provided in Section 1926 (b)(1).

• The State will conduct annual, random unannounced inspections as prescribed in Section 1926 (b)(2).

VII. Treatment Services for Pregnant Women, Section 1927

The State “…will ensure that each pregnant woman in the State who seeks or is referred for and would benefit from such services is given preference in admission to treatment facilities receiving funds pursuant to the grant.”

VIII. Additional Agreements, Section 1928

• Improvement of Process for Appropriate Referrals for Treatment, Section 1928(a)

• Continuing Education, Section 1928(b)

• Coordination of Various Activities and Services, Section 1928(c)

• Waiver of Requirement, Section 1928(d)

Form 3: Uniform Application for FY 2011 Substance Abuse Prevention and Treatment Block Grant

Funding Agreements/Certifications

As required by Title XIX , Part B, Subpart II and Subpart III of the PHS Act (continued)

IX. Submission to Secretary of Statewide Assessment of Needs, Section 1929

X. Maintenance of Effort Regarding State Expenditures, Section 1930

With respect to the principal agency of a State, the State “will maintain aggregate State expenditures for authorized activities at a level that is not less than the average level of such expenditures maintained by the State for the 2-year period preceding the fiscal year for which the State is applying for the grant.”

XI. Restrictions on Expenditure of Grant, Section 1931

XII. Application for Grant; Approval of State Plan, Section 1932

XIII. Opportunity for Public Comment on State Plans, Section 1941

The plan required under Section 1932 will be made “public in such a manner as to facilitate comment from any person (including any Federal person or any other public agency) during the development of the plan (including any revisions) and after the submission of the plan to the Secretary.”

XIV. Requirement of Reports and Audits by States, Section 1942

XV. Additional Requirements, Section 1943

XVI. Prohibitions Regarding Receipt of Funds, Section 1946

XVII. Nondiscrimination, Section 1947

XVIII. Services Provided By Nongovernmental Organizations, Section 1955

I hereby certify that the State or Territory will comply with Title XIX, Part B, Subpart II and Subpart III of the Public Health Service Act, as amended, as summarized above, except for those Sections in the Act that do not apply or for which a waiver has been granted or may be granted by the Secretary for the period covered by this agreement.

State:

Name of Chief Executive Officer or Designee:

Signature of CEO or Designee:

Title: Date Signed:

If signed by a designee, a copy of the designation must be attached

1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION The undersigned (authorized official signing for the applicant organization) certifies to the best of his or her knowledge and belief, that the applicant, defined as the primary participant in accordance with 45 C.F.R. Part 76, and its principals: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal Department or agency; (b) have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and (d) have not within a 3-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default. Should the applicant not be able to provide this certification, an explanation as to why should be placed after the assurances page in the application package. The applicant agrees by submitting this proposal that it will include, without modification, the clause titled "Certification Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion – Lower Tier Covered Transactions" in all lower tier covered transactions (i.e., transactions with sub-grantees and/or contractors) and in all solicitations for lower tier covered transactions in accordance with 45 C.F.R. Part 76.	2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS The undersigned (authorized official signing for the applicant organization) certifies that the applicant will, or will continue to, provide a drug-free work-place in accordance with 45 C.F.R. Part 76 by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the grantee’s workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing an ongoing drug-free awareness program to inform employees about – (1) The dangers of drug abuse in the workplace; (2) The grantee’s policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a) above; (d) Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment under the grant, the employee will – (1) Abide by the terms of the statement; and (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; (e) Notifying the agency in writing within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;
(f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with respect to any employee who is so convicted – (1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). For purposes of paragraph (e) regarding agency notification of criminal drug convictions, the DHHS has designated the following central point for receipt of such notices: Office of Grants and Acquisition Management Office of Grants Management Office of the Assistant Secretary for Management and Budget Department of Health and Human Services 200 Independence Avenue, S.W., Room 517-D Washington, D.C. 20201 3. CERTIFICATION REGARDING LOBBYING Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the Federal Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying undertaken with non-Federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 C.F.R. Part 93). The undersigned (authorized official signing for the his or her knowledge, and that he or she is aware that any false, fictitious, or fraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The undersigned agrees that the applicant organization will comply with the Public Health Service terms and conditions of award if a grant is awarded as a result of this application. 5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children’s services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children’s services provided in private residence, portions of facilities used for inpatient drug or alcohol treatment, service providers whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.	applicant organization) certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the under signed, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities, "in accordance with its instructions. (If needed, Standard Form-LLL, "Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this application form.) (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA) The undersigned (authorized official signing for the applicant organization) certifies that the statements herein are true, complete, and accurate to the best of By signing the certification, the undersigned certifies that the applicant organization will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The applicant organization agrees that it will require that the language of this certification be included in any subawards which contain provisions for children’s services and that all subrecipients shall certify accordingly. The Public Health Service strongly encourages all grant recipients to provide a smoke-free workplace and promote the non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL	TITLE
applicant organization	Date submitted

DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure.)

1. Type of Federal Action:

2. Status of Federal Action

3. Report Type:

 

a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance

 

a. bid/offer/application b. initial award c. post-award

 

a. initial filing b. material change

For Material Change Only:

Year

     

Quarter

     

date of last report

     

4. Name and Address of Reporting Entity:

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Prime Subawardee

     

Tier

     

, if known:

     

     

Congressional District, if known:

     

Congressional District, if known:

     

6. Federal Department/Agency:

7. Federal Program Name/Description:

     

     

CFDA Number, if applicable:

     

8. Federal Action Number, if known:

9. Award Amount, if known:

     

$      

10. a. Name and Address of Lobbying Entity (if individual, last name, first name, MI):

b. Individuals Performing Services (including address if different from No. 10a.) (last name, first name, MI):

     

     

11. Information requested through this form is authorized by title 31 U.S.C. Section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Print Name:

     

Title:

     

Telephone No.:

     

Date:

     

Federal Use Only:

     

Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97)

DISCLOSURE OF LOBBYING ACTIVITIES CONTINUATION SHEET
Reporting Entity:	     		Page	     	of	     
     

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. Section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks “subawardee”, then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 [e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency]. Include prefixes, e.g., ‘‘RFP-DE-90-001.’’ 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is OMB No.0348-0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.
ASSURANCES – NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant I certify that the applicant:
1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standard or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM’s Standard for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L.88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685- 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §§794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age;				(e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to non- discrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Title II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327- 333), regarding labor standards for federally assisted construction subagreements.
	10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetland pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.		13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§ 469a-1 et seq.). 14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.
	SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL	TITLE
		     
	APPLICANT ORGANIZATION				DATE SUBMITTED
	     				     

SECTION II: STATE PLAN – INTENDED USE OF FY 2011-2013

SUBSTANCE ABUSE PREVENTION AND TREATMENT

BLOCK GRANT FUNDS²

This section describes how the State will use the FY 2011 SAPT Block Grant award. The following is an overview of its information requirements:

Item		What you need to submit
1.	Planning	Narrative and checklist
2.	Needs assessment summary	Form 4
3.	Needs by age, sex, and race/ethnicity	Form 5 plus narrative
4.	Intended use plan	Form 6 and two checklists
5.	Purchasing services	Two Checklists
6.	Program performance monitoring	Checklist

THREE YEAR PLAN, ANNUAL REPORT, and PROGRESS REPORT:

PLAN FOR FY 2011-FY 2013 PROGRAM ACTIVITIES

This section documents the States plan to use the FY 2011 through FY 2013 Federal Substance Abuse Prevention and Treatment (SAPT) Block Grant. For each SAPT Block Grant award, the funds are available for obligation and expenditure for a 2-year period beginning on October 1 of the Federal Fiscal Year (FY) for which an award is made. States are encouraged to incorporate information on needs assessment, resource availability and States priorities in their plan to use these funds over the next three fiscal years. In the interim years (FY 2012 and FY 2013), updates to this 3-year plan are required; however, if the plan remains unchanged, additional narrative is not necessary. This section requires completion of needs assessment forms, services utilization forms and a narrative description of the States planning processes.

Planning: Needs Assessment and Utilization

1. Planning

This section provides an opportunity to describe the State’s planning processes and requires completion of needs assessment data forms, utilization information and a description of the State’s priorities. In addition, this section provides the State the opportunity to complete a three year intended use plan for the periods of FY 2011-FY 2013. Finally this section requires completion of planning narratives and a checklist. These items address compliance with the following statutory requirements:

• 42 U.S.C. §300x-29, 45 C.F. R. §96.133 and 45 C.F.R. §96.122(g)(13) require the State to submit a Statewide assessment of need for both treatment and prevention.

The State is to develop a 3-year plan which covers the three (3) fiscal years from FFY 2011-FY 2013. In a narrative of up to five pages, describe:

• How your State carries out sub-State area planning and determines which areas have the highest incidence, prevalence, and greatest need.

• Include a definition of your State’s sub-State planning areas (SPA).

• Identify what data is collected, how it is collected and how it is used in making these decisions.

• If there is a State, regional or local advisory council, describe their composition and their role in the planning process.

• Describe the monitoring process the State will use to assure that funded programs serve communities with the highest prevalence and need.

• Those States that have a State Epidemiological Outcomes Workgroup (SEOW) must describe its composition and contribution to the planning process for primary prevention and treatment planning. States are encouraged to utilize the epidemiological analyses and profiles to establish substance abuse prevention and treatment goals at the State level.

Describe how your State evaluates activities related to ongoing substance abuse prevention and treatment efforts, such as performance data, programs, policies and practices, and how this data is produced and used for planning. For the prevention assessment, States should focus on the SEOW process.  Describe State priorities and activities as they relate to addressing State and Federal priorities and requirements.

• 42 U.S.C. §300x-51 and 45 C.F. R. §96.123(a)(13) require the State to make the State plan public in such a manner as to facilitate public comment from any person during the development of the plan.

In a narrative of up to two pages, describe the process your State used to facilitate public comment in developing the State’s plan and its FY 2011-FY 2013 application for SAPT Block Grant funds.

For FY 2012 and FY 2013, only updates to the 3-year plan will be required. In the Section addressing the Federal Goals, the States will still need to provide Annual and Progress reports. Fiscal reporting requirements and performance data reporting will also be required annually.

The Prevention component of your Three Year Plan Should Include the Following:

Problem Assessment (Epidemiological Profile)

Using an array of appropriate data and information, describe the substance abuse-related problems in your State that you intend to address under Goal 2. Describe the criteria and rationale for establishing primary prevention priorities.

(See 45 C.F.R §96.133(a) (1))

Prevention System Assessment (Capacity and Infrastructure)

Describe the substance abuse prevention infrastructure in place at the State, sub-State, and local levels. Include in this description current capacity to collect, analyze, report, and use data to inform decision making; the number and nature of multi-sector partnerships at all levels, including broad-based community coalitions. In addition, describe the mechanisms the SSA has in place to support sub-recipients and community coalitions in implementing data-driven and evidence-based preventive interventions. If the State sets benchmarks, performance targets, or quantified objectives, describe the methods used by the State to establish these.

Prevention System Capacity Development

Describe planned changes to enhance the SSA’s ability to develop, implement, and support—at all levels—processes for performance management to include: assessment, mobilization, and partnership development; implementation of evidence-based strategies; and evaluation. Describe the challenges associated with these changes, and the key resources the State will use to address these challenges. Provide an overview of key contextual and cultural conditions that impact the State’s prevention capacity and functioning.

Implementation of a Data-Driven Prevention System

Describe the mechanism by which funding decisions are made and funds will be allocated. Explain how these mechanisms link funds to intended State outcomes. Provide an overview of any strategic prevention plans that exist at the State level, or which will be required at the sub-State or sub-recipient level, including goals, objectives, and/or outcomes. Indicate whether sub-recipients will be required to use evidence based programs and strategies. Describe the data collection and reporting requirements the State will use to monitor sub-recipient activities.

Evaluation of Primary Prevention Outcomes

Discuss the surveillance, monitoring, and evaluation activities the State will use to assess progress toward achieving its capacity development and substance abuse prevention performance targets. Describe the way in which evaluation results will be used to inform decision making processes and to modify implementation plans, including allocation decisions and performance targets.

Criteria for Allocating Funds

Use the following checklist to indicate the criteria your State will use in deciding how to allocate FY 2011-FY 2013 block grant funds. Mark all criteria that apply. Indicate the priority of the criteria by placing numbers in the boxes. For example, if the most important criterion is “incidence and prevalence levels,” put a “1” in the box beside that option. If two or more criteria are equal, assign them the same number.

 Population levels (Specify formula:_______________________________)

 Incidence and prevalence levels

 Problem levels as estimated by alcohol/drug-related crime statistics

 Problem levels as estimated by alcohol/drug-related health statistics

 Problem levels as estimated by social indicator data

 Problem levels as estimated by expert opinion

 Resource levels as determined by (specify method) .

 Size of gaps between resources (as measured by) and needs (as estimated by).

 Other (specify):

2. Needs assessment summary

These items involve completion of the Treatment Needs Assessment Summary Matrix (Form 4), the Treatment Needs by Age, Sex and Race/Ethnicity (Form 5), and a narrative explaining how the State arrived at the numbers entered on these forms, the biases of the data, and how the State intends to improve the reliability and validity of its data. This information is required by statute and regulation (See 42 U.S.C. §300x-29 and 45 C.F.R. §96.133).

Form 4 (Note: formerly Form 8)

How to complete the Treatment Needs Assessment Summary Matrix

Before you begin entering numbers, look at columns 6 and 7. It is the intent of Congress to target funding to areas severely impacted by substance use and trade. There are various ways to measure both the prevalence of substance-related criminal activity and the incidence of communicable diseases. With input from the States, CSAT has designated two indices for column 6 (Prevalence of substance-related criminal activity). These indices are:

• number of DWI (driving while intoxicated) arrests

• number of drug-related arrests

Before you begin to enter data, fill in the box over column 6 indicating the time period covered by the entries you will make in that column. The time period on which you report in this column is the last calendar year for which you have the data. In addition, you may use a third index of your choice for this column. If you choose to do so, write your index in the blank space in column 6C. If you choose not to enter a third index, cross out column 6C.

With input from the States, CSAT has designated three indices for column 7 (Incidence of communicable diseases). These indices are:

• number of cases of Hepatitis B per 100,000 population

• number of cases of AIDS per 100,000 population

• number of cases of Tuberculosis per 100,000 population

Following are instructions for completing each column:

Column 1: Sub-State planning area – Enter the name of each sub-State planning area.

Column 2: Total population – Enter the total population of the sub-State planning area.

Column 3: Total population in need – Enter on the left side (A) the area’s total population in need of substance abuse treatment services, including those already receiving treatment. Enter on the right side (B) those who would seek treatment but are not currently being served.

Column 4: Number of IVDUs in need – Enter on the left side (A) the area’s total number of IVDUs in need of treatment services, including those in treatment. Enter on the right side (B) those who would seek treatment but are not currently being served.

Column 5: Number of women in need – Enter on the left side (A) the area’s total number of women in need of treatment services, including those in treatment. Enter on the right side (B) those who would seek it but are not currently being served.

Column 6: Prevalence of substance-related criminal activity – Using the indices provided and the one you may have selected and written in, enter the appropriate numbers.

Column 7: Incidence of communicable diseases – Using the indices provided, enter the appropriate numbers. Do not enter data as fractions. For example, if there are 40.2 cases per 100,000 population, write “40.2” rather than “40.2/100,000.”

Form 4 (formerly Form 8)

Treatment Needs Assessment Summary Matrix

State:

Calendar Year _______

1. Substate planning area

2. Total population

3. Total population in need

4. Number of IVDUs in need

5. Number of women in need

6. Prevalence of substance-related criminal activity

7. Incidence of communicable diseases

A. Needing treatment services

B. That would seek treatment

A. Needing treatment services

B. That would seek treatment

A. Needing treatment services

B. That would seek treatment

A. Number of DWI arrests

B. Number of drug-related arrests

C. Other (specify):

A. Hepatitis B/ 100,000

B. AIDS/ 100,000

C. TB/ 100,000

3. Form 5 (formerly Form 9) Treatment Needs By Age, Sex, And Race/Ethnicity

The intent of Form 5 is to capture in column A the Total number of persons in need of treatment and then have this disaggregated among age, gender and race-ethnicity. The total of columns B through H should equal the total reported in column A (this total should also equal the sum of columns I and J).

These data aggregations by race and ethnicity are the categories required by the October 30, 1997 revision of OMB Statistical Policy Directive No. 15: Race and Ethnic Standards for Federal Statistics and Administrative Reporting (http://www.whitehouse.gov/omb/fedreg/ombdir15.html)

Form 5 (formerly Form 9)

Treatment Needs by Age, Sex, and Race/Ethnicity

State:

Sex and Race/Ethnicity

Age

A. TOTAL

B. WHITE

C. BLACK OR AFRICAN AMERICAN

D. NATIVE HAWAIIAN/ OTHER PACIFIC ISLANDER

E. ASIAN

F. AMERICAN INDIAN / ALASKA NATIVE

G. MORE THAN ONE RACE REPORTED

H. UNKNOWN

I. NOT HISPANIC OR LATINO

J. HISPANIC OR LATINO

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

1. 17 & Under

2. 18-24

3. 25-44

4. 45-64

5. 65 and over

6. Total

How your State determined the estimates for Form 4 and Form 5 (formerly Forms 8 and 9)

Under 42 U.S.C. §300x-29 and 45 C.F.R. §96.133, States are required to submit annually a needs assessment. This requirement is not contingent on the receipt of Federal needs assessment resources. States are required to use the best available data. Using up to three pages, explain what methods your State used to estimate the numbers of people in need of substance abuse treatment services, the biases of the data, and how the State intends to improve the reliability and validity of the data. Also indicate the sources and dates or timeframes for the data used in making these estimates reported in both Forms 4 and 5. This discussion should briefly describe how needs assessment data and performance data is used in prioritization of State service needs and informs the planning process to address such needs. The specific priorities that the State has established should be reported in Form 7. State priorities should include, but are not limited to the set of Federal program goals specified in the Public Health Service Act. In addition, provide any necessary explanation of the way your State records data or interprets the indices in columns 6 and 7, Form 4.

4. Form 6 (Note: formerly Form 11) Annual Intended Use Plan

This item requires the completion of the Intended Use Plan for the FY 2011 SAPT Block Grant (Form 6). The form is similar to the Substance Abuse State Agency Spending Report (Form 8) that you will complete in Section III of the application. Next year you will be directed to submit an Annual Intended Use Plan for the next Fiscal Year. To complete Row 1 through Row 6, please refer to the instructions for Form 8 found on page 62-63.

Row 1: Funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services - Enter the amount of funds from the FY 2011 SAPT Block Grant award and through other funding sources for this purpose. This includes funds used for alcohol and drug prevention (other than primary prevention) and treatment activities. This also includes direct services to patients, such as outreach, detoxification, methadone detoxification and maintenance, outpatient counseling, residential rehabilitation including therapeutic community stays, hospital-based care, vocational counseling, case management, central intake, and provider- or intermediary-level administration. Early intervention activities (other than primary prevention), substance abuse treatment and rehabilitation activities should be included as part of row 1. Do not include funds for State-level administration cost in this row.

Row 2: Primary Prevention

Row 3: Tuberculosis Services

Row 4: HIV Early Intervention Services - For FY 2011, 5 percent of the SAPT Block Grant award made available for such projects, such projected expenditures should be recorded on row 4, column A. This row is applicable to those “designated States” whose rate of cases of acquired immune deficiency syndrome is equal to or greater than the case rate specified in the statute (See 42 U.S.C. §300x-24(b) and 45 C.F.R. §96.128). The case rate data, as indicated by the number of such cases reported to and confirmed by the Director of the Centers for Disease Control and Prevention for the most recent calendar year for which such data are available, refers to such data that is available on or before October 1 of the Federal fiscal year for which the State is applying for a grant. ³

Row 5: Administration

Row 6: Column Total

Instructions for columns A through F: Remember to enter only those funds to be spent by the agency administering the FY 2011 SAPT Block Grant and to enter figures in whole dollar amounts.

Most States report that they use the full 24-month period to spend block grant funds. The intent is to determine how much funding from other sources is available to the principal agency of the State for substance abuse prevention and treatment services during the same period. Even if your State plans to spend the FY 2011 award in less than 24 months, report for the full 24-month period in columns B through F.

Column A: FY 2011 SAPT Block Grant – Enter the amounts of FY 2011 Block Grant funds your State plans to spend on each activity. Base your entities on the amount allocated under the President’s FY 2011 Budget Request. This budget has not yet been approved and is only an estimate. Those estimates are provided on pages CSAT-43 and CSAT-44 of the FY 2011 Justification of Estimates for Appropriations Committees (http://www.samhsa.gov/Budget/FY2011/index.aspx). Definitions of the funding sources in columns B through F are provided in the instructions for Form 8 in Section III of this application.

Column B: Medicaid – Base your entries on an estimate of Medicaid funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award.

Column C: Other Federal funds – Base your entries on an estimate of other Federal funds available for the 24-month period in which your State is permitted to spend the prior FY block grant award.

Column D: State funds – Base your entries on an estimate of State funds available for the 24-month period in which your State is permitted to spend the prior FY Block Grant award.

Column E: Local funds – Base your entries on an estimate of local funds available for the 24-month period in which your State is permitted to spend the prior FY Block Grant award.

Column F: Other – Base your entries on an estimate of other funds available for the 24-month period in which the State is permitted to spend the prior FY Block Grant award.

Intended Use Plan (Include ONLY funds to be spent by the agency administering the SAPT Block Grant. Estimated data are acceptable on this form.)
State:	Source of Funds
	(24 Month Projection)
Activity (See instructions for using Row 1.)	A. FY 2011 SAPT Block Grant	B. Medicaid (Federal, State, and local)	C. Other Federal Funds (e.g., Medicare, other public welfare)	D. State funds	E. Local funds (excluding local Medicaid)	F. Other
Substance Abuse Prevention* and Treatment
2. Primary Prevention
Tuberculosis Services
HIV Early Intervention Services
5. Administration (excluding program / provider level)
6. Column Total

* Prevention other than Primary Prevention

Form 6a and 6b: Detailing planned expenditures on primary prevention (See Form 6, Row 2)

Form 6a (Note: formerly Form 11a) Primary Prevention Planned Expenditures Checklist

Primary prevention activities are those directed at individuals who do not require treatment for substance abuse. In implementing the comprehensive primary prevention program, the State shall use a variety of strategies including but not limited to the six strategies listed below. If a State employs strategies not covered by these six categories, please report them under “Other” in a separate row for each one in Form 6a, or the State may choose to report activities utilizing the IOM Model of Universal Selective and Indicated in Form 6b. If a State chooses to complete Form 6b, a State must also complete Row 8, Section 1926–Tobacco on Form 6a. PLEASE NOTE CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

1. Information Dissemination: This strategy provides awareness and knowledge of the nature and extent of alcohol, tobacco and drug use, abuse and addiction and their effects on individuals, families and communities. It also provides knowledge and awareness of available prevention programs and services. Information dissemination is characterized by one-way communication from the source to the audience, with limited contact between the two. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Clearinghouse/information resource center(s);

(ii) Resource directories;

(iii) Media campaigns;

(iv) Brochures;

(v) Radio/TV public service announcements;

(vi) Speaking engagements;

(vii) Health fairs/health promotion; and

(viii) Information line.

(2) Education: This strategy involves two-way communication and is distinguished from the Information Dissemination strategy by the fact that interaction between the educator/facilitator and the participants is the basis of its activities. Activities under this strategy aim to affect critical life and social skills, including decision-making, refusal skills, critical analysis (e.g., of media messages) and systematic judgment abilities. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Classroom and/or small group sessions (all ages);

(ii) Parenting and family management classes;

(iii) Peer leader/helper programs;

(iv) Education programs for youth groups; and

(v) Children of substance abusers groups.

(3) Alternatives: This strategy provides for the participation of target populations in activities that exclude alcohol, tobacco and other drug use. The assumption is that constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by alcohol, tobacco and other drugs and would, therefore, minimize or obviate resort to the latter. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Drug free dances and parties;

(ii) Youth/adult leadership activities;

(iii) Community drop-in centers; and

(iv) Community service activities.

(4) Problem Identification and Referral: This strategy aims at identification of those who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted, however, that this strategy does not include any activity designed to determine if a person is in need of treatment. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Employee assistance programs;

(ii) Student assistance programs; and

(iii) Driving while under the influence/driving while intoxicated education

programs.

(5) Community-Based Process: This strategy aims to enhance the ability of the community to more effectively provide prevention and treatment services for alcohol, tobacco and drug abuse disorders. Activities in this strategy include organizing, planning, enhancing efficiency and effectiveness of services implementation, inter-agency collaboration, coalition building and networking. Examples of activities conducted and methods used for this strategy include (but are not limited to) the following:

(i) Community and volunteer training, e.g., neighborhood action training,

training of key people in the system, staff/officials training;

(ii) Systematic planning;

(iii) Multi-agency coordination and collaboration;

(iv) Accessing services and funding; and

5. Community team-building.

(6) Environmental: This strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of the abuse of alcohol, tobacco and other drugs used in the general population. This strategy is divided into two subcategories to permit distinction between activities which center on legal and regulatory initiatives and those that relate to the service and action-oriented initiatives. Examples of activities conducted and methods used for this strategy shall include (but not be limited to) the following:

(i) Promoting the establishment or review of alcohol, tobacco and drug use

policies in schools;

(ii) Technical assistance to communities to maximize local enforcement procedures governing availability and distribution of alcohol, tobacco, and other drug use;

(iii) Modifying alcohol and tobacco advertising practices; and

(iv) Product pricing strategies.

7. Other: The six primary prevention strategies have been designed to encompass nearly all of the prevention activities. However, in the unusual case an activity does not fit one of the six strategies it may be classified in the “Other” category.

Section 1926 - Tobacco

(8) Costs Associated with the Development and Conduct of Random, Unannounced Tobacco Inspections - Costs Associated with the Synar program. The Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants; Final Rule (45 C.F.R. §96.130) which was published in the January 19, 1996 Federal Register (61 FR 13) includes a provision which clarifies States may not use the Block Grant to fund the enforcement of their statute, except that they may expend funds from their primary prevention set aside of their Block Grant allotment under 45 C.F.R. §124(b)(1) for carrying out the administrative aspects of the requirements such as the development of the sample design and the conducting of the inspections.

States should include any non-SAPT funds that were allotted for Synar activities in the appropriate columns.

In addition, prevention strategies may be classified using the IOM Model of Universal, Selective and Indicated. Following are the definitions of those strategies. PLEASE NOTE: CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

Form 6b (Note: formerly Form 11b) Primary Prevention Planned Expenditures Checklist

Institute of Medicine Classification: Universal, Selective and Indicated:

Universal: Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

Universal Direct. Row 1—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, after-school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions)

Universal Indirect. Row 2—Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices).This also could include interventions involving programs and policies implemented by coalitions.

• Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels. (Adapted from The Institute of Medicine)

Form 6a: Primary Prevention Planned Expenditures Checklist

Estimated data are acceptable in this checklist.

FY 2011 Other

Block Grant Federal State Local Other

 Information

Dissemination $ $ $ $ $_____

 Education $ $ $ $ $_____

 Alternatives $ $ $ $ $_____

 Problem

Identification

and Referral $ $ $ $ $_____

 Community-

based Process $ $ $ $ $_____

 Environmental $ $ $ $ $_____

 Other $ $ $ $ $_____

 Section 1926- $ $ * $ * $ * $_____

Tobacco

TOTAL $ $ $ $ $

*Please list all sources, if possible (e.g., Center for Disease Control and Prevention block grant, foundations).

Form 6b: Primary Prevention Planned Expenditures Checklist

Estimated data are acceptable in this checklist.

FY 2011 Other

Block Grant Federal State Local Other

 Universal

Direct $ $ $ $ $_____

• Universal

• Indirect $ $ $ $ $_____

 Selective $ $ $ $ $_____

 Indicated $ $ $ $ $_____

TOTAL $ $ $ $ $

*Please list all sources, if possible (e.g., Center for Disease Control and Prevention block grant, foundations).

Form 6c (Note: formerly Form 11c) Resource Development Planned Expenditures Checklist

How to report planned expenditures on substance abuse resource development activities.

A State may plan to spend FY 2011 SAPT Block Grant funds on substance abuse resource development activities. These kinds of activities are described in Section III.1. Please complete the following checklist:

Does your State plan to fund resource development activities with FY 2011 SAPT Block Grant funds?

 Yes  No

If yes, show the estimated amounts that will be spent in the table below:

Additional

Treatment Prevention Combined Total

 Planning, coordination, $ $ $ $________

and needs assessment

 Quality assurance $ $ $ $________

 Training (post-employment) $ $ $ $________

 Education (pre-employment) $ $ $ $________

 Program development $ $ $ $________

 Research and evaluation $ $ $ $________

 Information systems $ $ $ $________

TOTAL $ $ $ $

Remember that resource development expenditures are not limited to row 5, Form 6 (Administration). You may plan resource development expenditures from rows 1 through 5.

5. Purchasing services

This item requires completing two checklists.

Methods for Purchasing

There are many methods the State can use to purchase substance abuse services. Use the following checklist to describe how your State will purchase services with the FY 2011 SAPT Block Grant award. Indicate the proportion of funding that is expended through the applicable procurement mechanism.

• Competitive grants Percent of Expense_____

• Competitive contracts Percent of Expense_____

• Non-competitive grants Percent of Expense_____

• Non-competitive contracts Percent of Expense_____

 Statutory or regulatory allocation to Percent of Expense_____

governmental agencies serving as

umbrella agencies that purchase or

directly operate services

• Other Percent of Expense_____

Total: 100%

(The total for the above categories should equal 100 percent.)

 According to county or Percent of Expense_____

regional priorities

Methods for Determining Prices

There are also alternative ways a State can decide how much it will pay for services. Use the following checklist to describe how the State pays for services. Complete any that apply. In addressing a State’s allocation of resources through various payment methods, a State may choose to report either the proportion of expenditures or proportion of clients served through these payment methods. Estimated proportions are acceptable.

 Line item program budget Percent of Clients Served_____

Percent of Expenditures______

 Price per slot Percent of Clients Served_____

Percent of Expenditures______

Rate: Type of slot:

Rate: Type of slot:

Rate: Type of slot:

 Price per unit of service Percent of Clients Served_____

Percent of Expenditures______

Unit: Rate:

Unit: Rate:

Unit: Rate:

 Per capita allocation (Formula): Percent of Clients Served_____

Percent of Expenditures_____

 Price per episode of care: Percent of Clients Served_____

Percent of Expenditures_____

Rate: Diagnostic group:

Rate: Diagnostic group:

Rate: Diagnostic group

6. Program performance monitoring

The purpose of this item is to document how the principal agency of the State will monitor and evaluate the performance of substance abuse service providers that receive State and/or SAPT Block Grant funds. Use the following checklist to indicate what methods your State uses. Check all that apply. When you are asked for frequency in the items below, use the following choices:

• monthly

• quarterly

• semi-annually

• annually

• every two years

 On-site inspections

Frequency for treatment: ( )

Frequency for prevention: ( )

 Activity reports

Frequency for treatment: ( )

Frequency for prevention: ( )

 Management information system

 Patient/participant data reporting system

Frequency for treatment: ( )

Frequency for prevention: ( )

 Performance contracts

 Cost reports

 Independent peer review

 Licensure standards - programs and facilities

Frequency for treatment: ( )

Frequency for prevention: ( )

 Licensure standards - personnel

Frequency for treatment: ( )

Frequency for prevention: ( )

• Other (Specify): `

Form 7 - State Priorities

How to complete Form 7: Report the State's top services priorities, up to twelve (12), based on needs assessment and performance management information. While it must be acknowledged that the 17 Federal Goals are service goals for your State program, not necessarily each and every one on the 17 Federal Goals is reflective of the specific service needs and target population identified by the State in its prioritization of State needs. Therefore, complete this form based on the State’s informed planning process and indicate the State’s self-identified service needs. If referencing a Federal Goal as a service need that matches the State’s identified services need, use only one specific Federal Goal per line.

	State Priorities
1
2
3
4
5
6
7
8
9
10
11
12

SECTION III: FEDERAL REQUIREMENTS, THREE YEAR PLAN; ANNUAL REPORT AND PROGRESS REPORT

This section documents the State’s plan to use the FY 2011 through FY 2013 Federal Substance Abuse Prevention and Treatment Block Grant. States are encouraged to incorporate information on needs assessment, resource availability and State priorities in their plan to use these funds over the next three fiscal years. States are also required to report on how the State used the FY 2008 award to meet the goals, objectives, and activities described in the FY 2008 application for funds and how the State is using its FY 2010 award. In the subsequent two years following this three year application, updates, if necessary, to the three year plan should be provided. If no updates to the plan are necessary, only reports on the recently closed out Federal Fiscal Year expenditure period (Annual Report) and on the ongoing Federal Fiscal Year expenditure period (Progress Report) are required. The ordering and formatting of WEB BGAS will be comparable to the MS Word version of this guidance.

In preparing this application, the State may find it helpful to review the FY 2008 and FY 2010 applications (and any modifications or revisions that may have been made) before you complete this section.

Section III refers to the statutory requirements of Title XIX, Part B, Subpart II and Subpart III of the PHS Act (See 42 U.S.C. §300x-21-66), as amended, and the associated regulatory requirements (See 45 C.F.R. Part 96).

By the time the State completes this report, the State will have spent the FY 2008 SAPT Block Grant award. Therefore, all financial data requested should be available.

This section has five items. It requires completing four checklists, addressing the 17 Federal Goals (narratives) for the State Plan (FY 2011-2013), the Annual report (FY 2008), and the Progress Report (2010), five forms, and four tables. Here is an overview of the requirements.

	Item	What you need to submit
1.	How substance abuse funds are to be/were used: FY 2011-FY 2013 State Plan or Intended Use, FY 2008 Annual Report; and FY 2010 Progress Report;	Narrative,
2.	Spending Report	Forms 8, 8a, 8b, and 8c
3.	Entity Inventory; Prevention Strategy Report	Form 9 and Form 9a
4.	Utilization Report	Forms 10a and 10b
5.	Maintenance of Effort (MOE) Tables: Total Single State Agency Expenditures for Substance Abuse; Statewide Non-Federal Expenditures for Tuberculosis Services for Substance Abusers in Treatment; Statewide Non-Federal Expenditures for HIV Early Intervention Services to Substance Abusers in Treatment; and Expenditures for Services to Pregnant Women and Women With Dependent Children (Maintenance)	Tables I – IV

1. Federal goals: How substance abuse funds will be used (State Plan), annual report and progress report (narratives).

Overall State Systems Narrative: A general narrative describing the States approach to synthesizing data sources and other information (e.g. needs data, outcome data, key informant, legislative priorities, etc.) should be provided including planned use of State and Federal resources. State priorities should be discussed. Activities and program priorities to be targeted, should be discussed and the integration of State priorities and Federal goals should be addressed.

NARRATIVES (FEDERAL GOALS (FY 2011-FY 2013, FY 2008, FY 2010)

In addressing Federal Goal 8, indicate whether or not the FY 2011 Annual Synar Report (See 42 U.S.C. §300x-26) is included with the FY 2011-FY 2013 uniform application. If the answer is no, indicate when the State plans to submit the report.

In addressing each of the Federal Goals for FY 2011-FY 2013, describe the State’s intended use of block grant funds and the specific treatment and primary prevention goals, objectives, and activities the State will carry out to achieve these objectives.

In addressing each of the Federal Goals for FY 2008 describe, in a brief narrative, how the SAPT Block Grant funds were used to meet the treatment and primary prevention goals, objectives, and activities spelled out in the State’s FY 2008 uniform application. Be sure to specify the primary prevention activities performed for each of the six strategies or using the Institute of Medicine (IOM) prevention classifications of Universal, Selective, and Indicated. Include a description of the State’s policies, procedures, and laws regarding substance abuse treatment, and information on what programs and activities were supported, what services were provided, and what progress was made (See 42 U.S.C. §300x-52 and 45 C.F.R. §122(f)(1)(ii)).

Note: States may wish to cite or reference policies, procedure and laws in these narratives however, if a state wishes to provide actual policy statements and/or laws it should do so in an appendix.

In addressing each of the Federal Goals for FY 2010, provide a description of the State’s progress in meeting the treatment and primary prevention goals, objectives, and activities included in the FY 2010 uniform application and a brief description of the recipients of block grant funds. For primary prevention, the description should also address the State’s progress in performing the activities for the six strategies or using the Institute of Medicine (IOM) prevention classifications of Universal, Selective, and Indicated articulated in the FY 2010 uniform application, as well (See 42 U.S.C. §300x-52 and 45 C.F.R. §96.122(f)(5)(i)).

In an effort to provide more concrete guidance on the essential points that must be covered in each of the narratives, the following questions must be addressed when responding to each.

(1) Who will be served – describe the target population and provide an estimate of the number of persons to be served in the target population;

(2) What activities/services will be provided, expanded, or enhanced – this may include activities/services by treatment modality or prevention strategy;

(3) When will the activities/services be implemented (date) – for ongoing activities/services, include information on the progress toward meeting the goals including dates on which integral activities/services began or will begin;

(4) Where in the State (geographic area) will the activities/services be undertaken – this may include counties, districts, regions, or cities;

5. How will the activities/services be operationalized – this may be through direct

procurement, subcontractors or grantees, or intra-governmental agreements.

As an example, in response to the narrative on planned activities/services regarding the expansion of existing or creation of new programs for pregnant women and women with dependent children, a State might provide the following information:

“It is planned in FY 2011-2013, to provide residential treatment services to 200 women with dependent children annually. In addition to providing residential treatment for women, facilities will be provided to allow the housing of minor children during the course of the treatment episode. This program is scheduled to be implemented in May 2011 in the four counties of the State that have the highest prevalence of substance abuse among women. We intend to fund this activity through a competitive contract with licensed, accredited providers in the four counties. In FY 2012 and FY 2013, it is intended to maintain this level of support.”

To complete the 17 Federal goals, objectives, and activities for the intended use plan, please address the Federal block grant requirements in a separate section first and then you may add an additional section describing other State requirements. List the specific objectives under each requirement and goal in priority order. Describe what activities the State plans to undertake to achieve these objectives. Include key elements in the State’s strategy to improve existing programs, create new ones, and remove barriers to improvement and expansion. Keep your discussion of each goal or requirement, its objectives, and activities to no more than one page per reporting period addressed (i.e., FYs 2011-2013, FY 2008, and FY 2010).

Requirements included in former Attachments (A-J) have been incorporated in the narrative report sections for each applicable goals; the Attachment forms are no longer presented separately.

GOAL # 1. Improving access to prevention and treatment services: The State shall expend block grant funds to maintain a continuum of substance abuse prevention and treatment services that meet these needs for the services identified by the State. Describe the continuum of block grant-funded prevention (with the exception of primary prevention; see Goal # 2 below) and treatment services available in the State (See 42 U.S.C. §300x-21(b) and 45 C.F.R. §96.122(f)(g)).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to: Providing comprehensive services; Using funds to purchase specialty program(s); Developing/maintaining contracts with provider; Providing local appropriations; Conducting training and/or technical assistance; Developing needs assessment information; Convening advisory groups, work groups, councils, or boards; Providing informational forum(s); and/or Conducting provider audits.

FY 2011- FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 2. Providing Primary Prevention services: An agreement to spend not less than 20 percent of the SAPT Block Grant on a broad array of primary prevention strategies directed at individuals not identified to be in need of treatment. Comprehensive primary prevention programs should include activities and services provided in a variety of settings for both the general population, and targeted sub-groups who are at high risk for substance abuse.

Specify the activities proposed for each of the six strategies or by the Institute of Medicine Model of Universal, Selective, or Indicated as defined below: (See 42 U.S.C.§300x-22(a)(1) and 45 C.F.R. §96.124(b)(1)).

Primary Prevention: Six (6) Strategies

• Information Dissemination – This strategy provides knowledge and increases awareness of the nature and extent of alcohol and other drug use, abuse, and addiction, as well as their effects on individuals, families, and communities. It also provides knowledge and increases awareness of available prevention and treatment programs and services. It is characterized by one-way communication from the source to the audience, with limited contact between the two.

• Education – This strategy builds skills through structured learning processes. Critical life and social skills include decision making, peer resistance, coping with stress, problem solving, interpersonal communication, and systematic and judgmental abilities. There is more interaction between facilitators and participants than in the information strategy.

• Alternatives – This strategy provides participation in activities that exclude alcohol and other drugs. The purpose is to meet the needs filled by alcohol and other drugs with healthy activities, and to discourage the use of alcohol and drugs through these activities.

• Problem Identification and Referral – This strategy aims at identification of those who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted however, that this strategy does not include any activity designed to determine if a person is in need of treatment.

• Community-based Process – This strategy provides ongoing networking activities and technical assistance to community groups or agencies. It encompasses neighborhood-based, grassroots empowerment models using action planning and collaborative systems planning.

• Environmental – This strategy establishes or changes written and unwritten community standards, codes, and attitudes, thereby influencing alcohol and other drug use by the general population.

Institute of Medicine Classification: Universal, Selective, and Indicated:

• Universal: Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Row 1—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, after school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Universal Indirect. Row 2—Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels. (Adapted from The Institute of Medicine Model of Prevention)

Note: In addressing this narrative the State may want to discuss activities or initiatives related to: Disseminating information to stakeholders; Providing education; Providing training/TA

Discussing environmental strategies; Identifying problems and/or making referrals; Providing alternative activities; Developing and/or maintaining sub-state contracts; Developing and/or disseminating promotional materials; Holding community forums/coalitions; Using or maintaining a management information system (MIS); Activities with advisory council, collaboration with State Incentive Grant (SIG) project; Delivering presentations; Data collection and/or analysis; Toll-free help/phone line provision; Procuring prevention services through competitive Request for Proposals (RFPs); Site monitoring visits

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 3. Providing specialized services for pregnant women and women with dependent children: An agreement to expend not less than an amount equal to the amount expended by the State for FY 1994 to establish and/or maintain new programs or expand and/or maintain the capacity of existing programs to make available treatment services designed for pregnant women and women with dependent children; and, directly or through arrangements with other public or nonprofit entities, to make available prenatal care to women receiving such treatment services; and, to make available child care while the women are receiving services (See 42 U.S.C. §300x-22(b)(1)(C) and 45 C.F.R. §96.124(c)(e)).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Prenatal care; Residential treatment services; Case management; Mental health services; Outpatient services; Education Referrals; Training/TA; Primary medical care; Day care/child care services; Assessment; Transportation; Outreach services; Employment services; Post-partum services; Relapse prevention; and Vocational services.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Additional instruction: Programs for Pregnant Women and Women with Dependent Children (Note: formerly Attachment B)

(See 42 U.S.C. §300x-22(b); 45 C.F.R. §96.124(c)(3); and 45 C.F.R.§96.122(f)(1)(viii))

For the fiscal year three years prior (FY 2008; Annual Report/Compliance) to the fiscal year for which the State is applying for funds:

Refer back to your Substance Abuse Entity Inventory (Form 9 formerly form 6). Identify those projects serving pregnant women and women with dependent children and the types of services provided in FY 2008. In a narrative of up to two pages, describe these funded projects.

Title XIX, Part B, Subpart II, of the PHS Act required the State to expend at least 5 percent of the FY 1993 and FY 1994 block grants to increase (relative to FY 1992 and FY 1993, respectively) the availability of treatment services designed for pregnant women and women with dependent children. In the case of a grant for any subsequent fiscal year, the State will expend for such services for such women not less than an amount equal to the amount expended by the State for fiscal year 1994.

In up to four pages, answer the following questions:

1. Identify the name, location (include sub-State planning area), Inventory of Substance Abuse Treatment Services (I-SATS) ID number (formerly the National Facility Register (NFR) number), level of care (refer to definitions in Section III.4), capacity, and amount of funds made available to each program designed to meet the needs of pregnant women and women with dependent children.

2. What did the State do to ensure compliance with 42 U.S.C. §300x-22(b)(1)(C) in spending FY 2008 Block Grant and/or State funds?

3. What special methods did the State use to monitor the adequacy of efforts to meet the special needs of pregnant women and women with dependent children?

4. What sources of data did the State use in estimating treatment capacity and utilization by pregnant women and women with dependent children?

5. What did the State do with FY 2008 Block Grant and/or State funds to establish new programs or expand the capacity of existing programs for pregnant women and women with dependent children?

GOAL # 4. Services to intravenous drug abusers: An agreement to provide treatment to intravenous drug abusers that fulfills the 90 percent capacity reporting, 14-120 day performance requirement, interim services, outreach activities and monitoring requirements (See 42 U.S.C. §300x-23 and 45 C.F.R. §96.126).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Interim services; Outreach Waiting list(s); Referrals; Methadone maintenance; Compliance reviews; HIV/AIDS testing/education; Outpatient services; Education; Risk reduction; Residential services; Detoxification; and Assessments.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Additional Instruction: Programs for Intravenous Drug Users (IVDUs) (Note: formerly Attachment C)

(See 42 U.S.C. §300x-23; 45 C.F.R. §96.126; and 45 C.F.R. §96.122(f)(1)(ix))

For the fiscal year three years prior (FY 2008; Annual Report/Compliance) to the fiscal year for which the State is applying for funds:

1. How did the State define IVDUs in need of treatment services?

2. 42 U.S.C. §300x-23(a)(1) requires that any program receiving amounts from the grant to provide treatment for intravenous drug abuse notify the State when the program has reached 90 percent of its capacity. Describe how the State ensured that this was done. Please provide a list of all such programs that notified the State during FY 2008 and include the program’s I-SATS ID number (See 45 C.F.R. §96.126(a)).

3. 42 U.S.C. §300x-23(a)(2)(A)(B) requires that an individual who requests and is in need of treatment for intravenous drug abuse is admitted to a program of such treatment within 14-120 days. Describe how the State ensured that such programs were in compliance with the 14-120 day performance requirement (See 45 C.F.R. §96.126(b)).

4. 42 U.S.C. §300x-23(b) requires any program receiving amounts from the grant to provide treatment for intravenous drug abuse to carry out activities to encourage individuals in need of such treatment to undergo treatment. Describe how the State ensured that outreach activities directed toward IVDUs was accomplished (See 45 C.F.R. §126(e)).

Additional Instruction: Program Compliance Monitoring (Note: formerly Attachment D)

(See 45 C.F.R. §96.122(f)(3)(vii))

The Interim Final Rule (45 C.F.R. Part 96) requires effective strategies for monitoring programs’ compliance with the following sections of Title XIX, Part B, Subpart II of the PHS Act: 42 U.S.C. §300x-23(a); 42 U.S.C. §300x-24(a); and 42 U.S.C. §300x-27(b).

For the fiscal year two years prior (FY 2009) to the fiscal year for which the State is applying for funds:

In up to three pages provide the following:

• A description of the strategies developed by the State for monitoring compliance with each of the sections identified below; and

• A description of the problems identified and corrective actions taken:

1. Notification of Reaching Capacity 42 U.S.C. §300x-23(a)

(See 45 C.F.R. §96.126(f) and 45 C.F.R. §96.122(f)(3)(vii));

2. Tuberculosis Services 42 U.S.C. §300x-24(a)

(See 45 C.F.R. §96.127(b) and 45 C.F.R. §96.122(f)(3)(vii)); and

3. Treatment Services for Pregnant Women 42 U.S.C. §300x-27(b)

(See 45 C.F.R. §96.131(f) and 45 C.F.R. §96.122(f)(3)(vii)).

GOAL # 5. An agreement, directly or through arrangements with other public or nonprofit private entities, to routinely make available tuberculosis services to each individual receiving treatment for substance abuse and to monitor such service delivery (See 42 U.S.C. §300x-24(a) and 45 C.F.R. §96.127).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Compliance monitoring: Referrals; Screening; PPD or Mantoux Skin tests; Provider contracts; Site visits/reviews; Assessments; Counseling; Training/TA; Cooperative agreements; Case management; Wait lists; Promotional materials

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 6. An agreement, by designated States, to provide treatment for persons with substance abuse problems with an emphasis on making available within existing programs early intervention services for HIV in areas of the State that have the greatest need for such services and to monitor such service delivery (See 42 U.S.C. §300x-24(b) and 45 C.F.R. §96.128).

Note: If the State is or was for the reporting periods listed a designated State, in addressing this narrative the State may want to discuss activities or initiatives related to the provision of: HIV testing; Counseling; Provider contracts; Training/TA Education; Screening/assessment; Site visits/reviews; Rapid HIV testing; Referral; Case management; Risk reduction; and HIV-related data collection

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Additional Instructions: Tuberculosis (TB) and Early Intervention Services for HIV (Note: formerly Attachment E)

(See 45 C.F.R. §96.122(f)(1)(x))

For the fiscal year three years prior (FY 2008; Annual Report/Compliance) to the fiscal year for which the State is applying for funds:

Provide a description of the State’s procedures and activities and the total funds expended for tuberculosis services. If a “designated State,” provide funds expended for early intervention services for HIV. Please refer to the FY 2008 Uniform Application, Section III.4, FY 2008 Intended Use Plan (Form 11), and Appendix A, List of HIV Designated States, to confirm applicable percentage and required amount of SAPT Block Grant funds expended for early intervention services for HIV.

Examples of procedures include, but are not limited to:

• development of procedures (and any subsequent amendments), for tuberculosis services and, if a designated State, early intervention services for HIV, e.g., Qualified Services Organization Agreements (QSOA) and Memoranda of Understanding (MOU);

• the role of the Single State Agency (SSA) for substance abuse prevention and treatment; and

• the role of the Single State Agency for public health and communicable diseases.

Examples of activities include, but are not limited to:

• the type and amount of training made available to providers to ensure that tuberculosis services are routinely made available to each individual receiving treatment for substance abuse;

• the number and geographic locations (include sub-State planning area) of projects delivering early intervention services for HIV;

• the linkages between IVDU outreach (See 42 U.S.C. §300x-23(b) and 45 C.F.R. §96.126(e)) and the projects delivering early intervention services for HIV; and

• technical assistance.

GOAL # 7. An agreement to continue to provide for and encourage the development of group homes for recovering substance abusers through the operation of a revolving loan fund (See 42 U.S.C. §300x-25). Effective FY 2001, the States may choose to maintain such a fund. If a State chooses to participate, reporting is required.

Note: If this goal is no longer applicable because the project was discontinued, please indicate.

If the loan fund is continuing to be used, please indicate and discuss distribution of loan applications; training/TA to group homes; loan payment collections; Opening of new properties; Loans paid off in full; and loans identified as in default.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Additional instructions: Group Home Entities and Programs (Note: formerly Attachment F)

(See 42 U.S.C. §300x-25)

If the State has chosen in FY 2008 to participate and support the development of group homes for recovering substance abusers through the operation of a revolving loan fund, the following information must be provided.

Provide a list of all entities that have received loans from the revolving fund during FY 2008 to establish group homes for recovering substance abusers. In a narrative of up to two pages, describe the following:

• the number and amount of loans made available during the applicable fiscal years;

• the amount available in the fund throughout the fiscal year;

• the source of funds used to establish and maintain the revolving fund;

• the loan requirements, application procedures, the number of loans made, the number of repayments, and any repayment problems encountered;

• the private, nonprofit entity selected to manage the fund;

• any written agreement that may exist between the State and the managing entity;

• how the State monitors fund and loan operations; and

• any changes from previous years’ operations.

GOAL # 8. An agreement to continue to have in effect a State law that makes it unlawful for any manufacturer, retailer, or distributor of tobacco products to sell or distribute any such product to any individual under the age of 18; and, to enforce such laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under age 18 (See 42 U.S.C. §300x-26, 45 C.F.R. §96.130 and 45 C.F.R. §96.122(d)).

• Is the State’s FY 2011 Annual Synar Report included with the FY 2011 uniform application?

Yes No

• If No, please indicate when the State plans to submit the report:

mm/dd/2010

Note: The statutory due date is December 31, 2010.

GOAL # 9. An agreement to ensure that each pregnant woman be given preference in admission to treatment facilities; and, when the facility has insufficient capacity, to ensure that the pregnant woman be referred to the State, which will refer the woman to a facility that does have capacity to admit the woman, or if no such facility has the capacity to admit the woman, will make available interim services within 48 hours, including a referral for prenatal care (See 42 U.S.C. §300x-27 and 45 C.F.R. §96.131).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Priority admissions; Referral to Interim services; Prenatal care; Provider contracts; Routine reporting; Waiting lists; Screening/assessment; Residential treatment; Counseling; Training/TA Educational materials; HIV/AIDS/TB Testing

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Additional instructions: Capacity Management and Waiting List Systems (Note: formerly Attachment G)

(See 45 C.F.R. §96.122(f)(3)(vi))

For the fiscal year two years prior (FY 2009) to the fiscal year for which the State is applying for funds:

In up to five pages, provide a description of the State’s procedures and activities undertaken, and the total amount of funds expended (or obligated if expenditure data is not available), to comply with the requirement to develop capacity management and waiting list systems for intravenous drug users and pregnant women (See 45 C.F.R. §96.126(c) and 45 C.F.R. §96.131(c), respectively). This report should include information regarding the utilization of these systems. Examples of procedures may include, but not be limited to:

• development of procedures (and any subsequent amendments) to reasonably implement a capacity management and waiting list system;

• the role of the Single State Agency (SSA) for substance abuse prevention and treatment;

• the role of intermediaries (county or regional entity), if applicable, and substance abuse treatment providers; and

• the use of technology, e.g., toll-free telephone numbers, automated reporting systems, etc.

Examples of activities may include, but not be limited to:

• how interim services are made available to individuals awaiting admission to treatment;

• the mechanism(s) utilized by programs for maintaining contact with individuals awaiting admission to treatment; and

• technical assistance.

GOAL # 10. An agreement to improve the process in the State for referring individuals to the treatment modality that is most appropriate for the individual (See 42 U.S.C. §300x-28(a) and 45 C.F.R. §96.132(a)).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Training/TA; Implementation of ASAM criteria; Use of Standardized assessments; Patient placement using levels of care; Purchased/contracted services; Monitoring visits/inspections; Work groups/task forces; Information systems; Reporting mechanisms; Implementation protocols; Provider certifications.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 11. An agreement to provide continuing education for the employees of facilities which provide prevention activities or treatment services (or both as the case may be) (See 42 U.S.C. §300x-28(b) and 45 C.F.R. §96.132(b)).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Counselor certification; Co-occurring training; ATTCs training; Motivational interviewing training; HIV/AIDS/TB training; Ethics training; Confidentiality and privacy training; Special populations training; Case management training; Train-the-trainer model; Domestic violence training; Faith-based training; Suicide prevention training; Crisis intervention training.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 12. An agreement to coordinate prevention activities and treatment services with the provision of other appropriate services (See 42 U.S.C. §300x-28(c) and 45 C.F.R. §96.132(c)).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Convened work groups/task force/councils; Conduct training/TA; Partnering with association(s)/other agencies; Coordination of prevention and treatment activities; Convening routine meetings; Development of polices for coordination; Convening town hall meetings to raise public awareness; Implementation of evidence-based services.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 13. An agreement to submit an assessment of the need for both treatment and prevention in the State for authorized activities, both by locality and by the State in general (See 42 U.S.C. §300x-29 and 45 C.F.R. §96.133).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Data-based planning; Statewide surveys; Youth survey(s); Archival/social indicator data; Data work groups; Risk and protective factors Household survey data utilization; Prioritization of services; Provider surveys; Online surveys/Web-based reporting systems; Site visits.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 14. An agreement to ensure that no program funded through the Block Grant will use funds to provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs (See 42 U.S.C. §300x-31(a)(1)(F) and 45 C.F.R. §96.135(a)(6)).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Prohibitions written into provider contracts; Compliance site visits; Peer reviews; Training/TA.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL # 15. An agreement to assess and improve, through independent peer review, the quality and appropriateness of treatment services delivered by providers that receive funds from the block grant (See 42 U.S.C. §300x-53(a) and 45 C.F.R. §96.136).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Peer review process and/or protocols; Quality control/quality improvement activities; Review of treatment planning reviews; Review of assessment process; Review of admission process; Review of discharge process; achieving CARF/JCAHO/(etc) accreditation.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Additional instructions: Independent Peer Review (Note: formerly Attachment H) (See 45 C.F.R. §96.122(f)(3)(v))

In up to three pages provide a description of the State’s procedures and activities undertaken to comply with the requirement to conduct independent peer review during FY 2008 (See 42 U.S.C. §300x-53(a)(1) and 45 C.F.R. §96.136).

Examples of procedures may include, but not be limited to:

• the role of the Single State Agency (SSA) for substance abuse prevention activities and treatment services in the development of operational procedures implementing independent peer review;

• the role of the State Medical Director for Substance Abuse Services in the development of such procedures;

• the role of the independent peer reviewers; and

• the role of the entity(ies) reviewed.

Examples of activities may include, but not be limited to:

• the number of entities reviewed during the applicable fiscal year;

• technical assistance made available to the entity(ies) reviewed; and

• technical assistance made available to the reviewers, if applicable.

GOAL # 16. An agreement to ensure that the State has in effect a system to protect patient records from inappropriate disclosure (See 42 U.S.C. §300x-53(b), 45 C.F.R. §96.132(e), and 42 C.F.R. Part 2).

Note: In addressing this narrative the State may want to discuss activities or initiatives related to the provision of: Confidentiality training/TA; Compliance visits/inspections; Licensure requirements/reviews; Corrective action plans; Peer reviews.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

GOAL #17. An agreement to ensure that the State has in effect a system to comply with services provided by non-governmental organizations (See 42 U.S.C. §300x-65 and 42 C.F.R. part 54 (See 42 C.F.R. §54.8(b) and §54.8(c)(4), Charitable Choice Provisions; Final Rule (68 FR 189, pp. 56430-56449, September 30, 2003).

Note: In addressing this narrative please specify if this provision was not applicable because State did not fund religious providers. If the State did fund religious providers, it may want to discuss activities or initiatives related to the provision of: Training/TA on regulations; Regulation reviews; Referral system/process; Task force/work groups; Provider surveys; Request for proposals; Administered vouchers to ensure patient choice.

FY 2011-FY 2013 (Intended Use/Plan):

FY 2008 (Annual Report/Compliance):

FY 2010 (Progress):

Under Charitable Choice, States, local governments, and religious organizations, each as SAMHSA grant recipients, must: (1) ensure that religious organizations that are providers provide notice of their right to alternative services to all potential and actual program beneficiaries (services recipients); (2) ensure that religious organizations that are providers refer program beneficiaries to alternative services; and (3) fund and/or provide alternative services. The term “alternative services” means services determined by the State to be accessible and comparable and provided within a reasonable period of time from another substance abuse provider (“alternative provider”) to which the program beneficiary (“services recipient”) has no religious objection. The purpose of Attachment I is to document how your State is complying with these provisions.

Additional instructions: Charitable Choice (Note: formerly Attachment I)

For the fiscal year prior (FY 2010) to the fiscal year for which the State is applying for funds check the appropriate box(es) that describe the State’s procedures and activities undertaken to comply with the provisions.

Notice to Program Beneficiaries – Check all that apply:

 Used model notice provided in final regulations.

• Used notice developed by State (please attach a copy in Appendix A).

• State has disseminated notice to religious organizations that are providers.

• State requires these religious organizations to give notice to all potential beneficiaries.

Referrals to Alternative Services – Check all that apply:

• State has developed specific referral system for this requirement.

• State has incorporated this requirement into existing referral system(s).

 SAMHSA’s Treatment Facility Locator is used to help identify providers.

 Other networks and information systems are used to help identify providers.

 State maintains record of referrals made by religious organizations that are providers.

 Enter total number of referrals necessitated by religious objection to other

substance abuse providers (“alternative providers”), as defined above, made in

previous fiscal year. Provide total only; no information on specific referrals

required.

Brief description (one paragraph) of any training for local governments and faith-based and community organizations on these requirements.

Additional instructions: Waivers (Note: formerly Attachment J)

If your State plans to apply for any of the following waivers, check the appropriate box and submit the request for a waiver as an attachment to the application or following the submission of the application.

 To expend not less than an amount equal to the amount expended by the State for FY 1994 to establish new programs or expand the capacity of existing programs to make available treatment services designed for pregnant women and women with dependent children (See 42 U.S.C. §300x-22(b)(2) and 45 C.F.R. §96.124(d)).

 Rural area early intervention services HIV requirements

(See 42 U.S.C. §300x-24(b)(5)(B) and 45 C.F.R. §96.128(d))

 Improvement of process for appropriate referrals for treatment, continuing education, or coordination of various activities and services

(See 42 U.S.C. §300x-28(d) and 45 C.F.R. §96.132(d))

 Statewide maintenance of effort (MOE) expenditure level

(See 42 U.S.C. §300x-30(c) and 45 C.F.R. §96.134(b))

 Construction/rehabilitation

(See 42 U.S.C. §300x-31(c) and 45 C.F.R. §96.135(d))

If the State proposes to request a waiver at this time for one or more of the above provisions, include the waiver request as an attachment to the application, if possible. The Interim Final Rule, 45 C.F.R. §96.124(d), §96.128(d), §96.132(d), §96.134(b), and §96.135(d), contains information regarding the criteria for each waiver, respectively. A formal waiver request must be submitted to the SAMHSA Administrator following the submission of the application if not included as an attachment to the application.

2. Form 8 (Note: formerly Form 4) Preparing to complete the Substance Abuse State Agency Spending Report

This form requires you to enter amounts of funds, by source, for each kind of activity. You will enter only funds flowing through the principal agency of the State that administered the SAPT Block Grant. Amounts must be entered in whole dollar amounts. Before you begin completing the form, do the following:

• Enter the State’s name in the box at the upper left.

• Enter in the box at the upper right the dates of the State expenditure period you identified on the Face Page (Form 1).

• Read the instructions carefully.

• Study the definitions of the row and column headings.

How to complete Form 8

First review the definitions of the activities listed at the left. Then make sure you understand which funding sources are entered in column A and which ones are entered in columns B through F.

Rows 1 through 5 – Activities

Rows 1 through 5 describe typical activities funded by the agency administering the SAPT Block Grant.

 Note: Do not include expenditures for primary prevention in Row 1.

Row 1: Funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services – Enter the amount of funds from the FY 2008 award and through other funding sources for this purpose. This includes funds used for alcohol and drug prevention (other than primary prevention) and treatment activities. This also includes direct services to patients, such as outreach, detoxification, methadone detoxification and maintenance, outpatient counseling, residential rehabilitation including therapeutic community stays, hospital-based care, vocational counseling, case management, central intake, and program administration. Early intervention activities (other than primary prevention), substance abuse treatment and rehabilitation activities should be included as part of row 1. Do not include funds for administration cost in this row.

Row 2: Primary Prevention – This row collects information on primary prevention activities funded under the FY 2008 SAPT Block Grant and through other funding sources. Primary prevention includes activities directed at individuals who do not require treatment for substance abuse. Such activities may include education, mentoring, and other activities designed to reduce the risk of substance abuse by individuals. Note that under the SAPT Block Grant statute, early intervention activities should not be included as part of primary prevention.

Row 3: Tuberculosis Services – This row collects information on tuberculosis services made available to individuals receiving treatment for substance abuse. Tuberculosis services include counseling, testing, and treatment for the disease. Funds made available from the grant to provide such services, either directly or through arrangements with other public or nonprofit private entities, should be recorded on row 3, column A.

Row 4: HIV Early Intervention Services – This row collects information on 1 or more projects established to make available early intervention services for HIV disease at the sites in which individuals are receiving treatment for substance abuse. For FY 2008, 5 percent of the SAPT Block Grant award made available to establish such projects should be recorded on row 4, column A. This row is applicable to those “designated States” whose rate of cases of acquired immune deficiency syndrome is equal to or greater than the case rate specified in the statute (See 42 U.S.C. §300x-24(b) and 45 C.F.R. §96.128). The case rate data, as indicated by the number of such cases reported to and confirmed by the Director of the Centers for Disease Control and Prevention for the most recent calendar year for which such data are available,⁴ refers to such data that is available on or before October 1 of the fiscal year for which the State is applying for a grant.

Row 5: Administration – This includes grants and contracts management, policy and auditing, personnel management, legislative liaison, and other overhead costs in large departments and agencies. For FY 2008, a maximum of 5 percent of the SAPT Block Grant may have been spent on administration at the State level.

Do not account for administration at the program (or service provider) level on this row. Program level administration expenditures should be accounted for in Rows 1 - 4 above, as appropriate.

Row 6: Column Total – Use this row to enter the total of Rows 1 through 5. The column A total amount should equal the amount of and may not exceed the FY 2008 SAPT Block Grant that appears on line 8 of the FY 2008 Notice of Block Grant Award (NGA).

Column A – Expenditures of SAPT Block Grant

Use this column to record your State’s use of FY 2008 SAPT Block Grant award. In column A, enter FY 2008 block grant funds that were spent on each activity. Remember to enter amounts in whole dollar amounts.

Columns B through F – Expenditures of other funds

Use these columns to report on funds from other sources spent by the designated substance abuse agency during the 12-month expenditure period you entered in the box (Same as Form 1). Thus, the time period on which you report here is different from the one covered by column A. Here are the definitions for each column:

Column B: Medicaid – Enter the total of all Federal, State and local match Medicaid (Title XVIX of the Social Security Act) funds in this column.

Column C: Other Federal funds – This includes all other Federal funds for substance abuse that flow through the principal agency. Examples are HHS or other Federal categorical grant funds, Medicare, other public welfare funds such as Food Stamps (Title VIII), other public third party funds such as CHAMPUS, the Social Services Block Grant (Title XX), and the Maternal and Child Health Block Grant (Title V). Do not include Federal funds that go through other State offices/agencies or directly to providers.

Column D: State funds – This includes all State general funds or special appropriations administered by the principal agency, such as fines, fees, and earmarked taxes. This column provides an estimate of annual State funding.

Column E: Local funds – This includes appropriations from local government entities such as cities, other municipalities, special tax districts, and counties. Remember that local Medicaid match funds were reported in column B. Do not report them again here.

Column F: Other funds – This includes funds from all other sources such as patient fees, nonprofit private entities like the United Way and the Robert Wood Johnson Foundation, and private third party payers such as Blue Cross/Blue Shield, health maintenance organizations, and other commercial insurers. If your agency receives no local or other funds, enter zeroes in columns E and F.

Form 8 (formerly Form 4) Substance Abuse State Agency Spending Report (Include ONLY funds flowing through the agency.)
State:			Dates of State expenditure period: from ____________ to ____________ (Same as Form 1)
	Source of Funds
Activity (See instructions for using Row 1)	A. SAPT Block Grant		B. Medicaid (Federal, State, and Local)	C. Other Federal funds (e.g., Medicare, other public welfare)	D. State funds	E. Local funds (Excluding local Medicaid)	F. Other
	FY 2008 Award (spent)
1. Substance Abuse Prevention * and Treatment
2. Primary Prevention
3. Tuberculosis Services
4. HIV Early Intervention Services
5. Administration (excluding program/provider level)
6. Column Total

* Prevention other than Primary Prevention

Primary Prevention Expenditures Checklist (Form 8a & 8b)

Forms 8a and 8b: Detailing expenditures on primary prevention (Form 8, Row 2)

There are six primary prevention strategies typically funded by principal agencies administering the SAPT Block Grant. Below are the definitions of those strategies. Expenditures within each of the six strategies or IOM Model should be directly associated with the cost of completing the activity or task, for example information dissemination should include the cost of developing pamphlets, the time of participating staff or the cost of public service announcements etc. (Reference Section II Planning). If a State employs strategies not covered by these six categories, please report them under “Other” in a separate row for each one in Form 8a. If the State chooses to report activities utilizing the IOM Model of Universal, Selective, and Indicated; complete Form 8b. If Form 8b is completed, the State must also complete Row 8, Section 1926 –Tobacco on Form 8a.

PLEASE NOTE: CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

Primary Prevention Expenditures Checklist (Form 8a) (Note: formerly Form 4a)

Information Dissemination – This strategy provides knowledge and increases awareness of the nature and extent of alcohol and other drug use, abuse, and addiction, as well as their effects on individuals, families, and communities. It also provides knowledge and increases awareness of available prevention and treatment programs and services. It is characterized by one-way communication from the source to the audience, with limited contact between the two.

Education – This strategy builds skills through structured learning processes. Critical life and social skills include decision making, peer resistance, coping with stress, problem solving, interpersonal communication, and systematic and judgmental abilities. There is more interaction between facilitators and participants than in the information strategy.

Alternatives – This strategy provides participation in activities that exclude alcohol and other drugs. The purpose is to meet the needs filled by alcohol and other drugs with healthy activities, and to discourage the use of alcohol and drugs through these activities.

Problem Identification and Referral – This strategy aims at identification of those who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted however, that this strategy does not include any activity designed to determine if a person is in need of treatment.

Community-based Process – This strategy provides ongoing networking activities and technical assistance to community groups or agencies. It encompasses neighborhood-based, grassroots empowerment models using action planning and collaborative systems planning.

Environmental – This strategy establishes or changes written and unwritten community standards, codes, and attitudes, thereby influencing alcohol and other drug use by the general population.

Other – The six primary prevention strategies have been designed to encompass nearly all of the prevention activities. However, in the unusual case an activity does not fit one of the six strategies it may be classified in the “Other” category.

Section 1926 – Tobacco: Costs Associated with the Synar Program. Per January 19, 1996, 45 C.F.R. Part 96, Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants; Final Rule (45 C.F.R. §96.130), States may not use the Block Grant to fund the enforcement of their statute, except that they may expend funds from their primary prevention set aside of their Block Grant allotment under 45 C.F.R. §96.124(b)(1) for carrying out the administrative aspects of the requirements such as the development of the sample design and the conducting of the inspections.

States should include any non-SAPT Block Grant funds that were allotted for Synar activities in the appropriate columns.

In addition, prevention strategies may be classified using the IOM Model of Universal, Selective and Indicated. Here are the definitions of those strategies. PLEASE NOTE: CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926–TOBACCO.

Form 8b (Note: formerly Form 4b) Primary Prevention Expenditures Checklist

Institute of Medicine Classification: Universal, Selective and Indicated:

Universal: Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

Universal Direct. Row 1—Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, after-school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions)

Universal Indirect. Row 2—Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices).This also could include interventions involving programs and policies implemented by coalitions.

• Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels. (Adapted from The Institute of Medicine)

Refer back to Form 8 and look at all the entries you made on row 2 primary prevention. Use the table below to indicate how much funding supported each of the six strategies on Form 8a or how much funding supported each of the IOM classifications, Universal, Selective or Indicated on Form 8b. Enter in whole dollar amounts. For sources of funds other than the SAPT Block Grant, report only those funds made available during the 24 month expenditure period identified on Form 8.

Form 8a (formerly Form 4a): Primary Prevention Expenditures Checklist

	SAPT Block Grant FY 2008	Other Federal	State	Local	Other
Information Dissemination	$	$	$	$	$
Education	$	$	$	$	$
Alternatives	$	$	$	$	$
Problem Identification & Referral	$	$	$	$	$
Community-based process	$	$	$	$	$
Environmental	$	$	$	$	$
Other	$	$	$	$	$
Section 1926 - Tobacco	$	$ *	$ *	$ *	$ *
TOTAL	$	$	$	$	$

*Please list all sources, if possible (e.g., Centers for Disease Control and Prevention block grant, foundations).

Form 8b (formerly Form 4b): Primary Prevention Expenditures Checklist

	SAPT Block Grant FY 2008	Other Federal	State	Local	Other
Universal Direct	$	$	$	$	$
Universal Indirect	$	$	$	$	$
Selective	$	$	$	$	$
Indicated	$	$	$	$	$
TOTAL	$	$	$	$	$

*Please list all sources, if possible (e.g., Centers for Disease Control and Prevention block grant, foundations).

Form 8c (Note: formerly Form 4c): Resource Development Expenditures Checklist: How to report expenditures on substance abuse resource development activities

Expenditures on resource development activities may involve the time of State or sub-State personnel, or other State or sub-State resources. These activities may also be funded through contracts, grants, or agreements with other entities. Look at the following definitions to see if your State made these kinds of expenditures with the FY 2008 SAPT Block Grant award (column A on Form 8). Your State may use different terminology or a different classification system to describe these kinds of activities. Just do the best you can in converting your terminology into these seven categories.

Planning, coordination, and needs assessment – This includes State, regional, and local personnel salaries prorated for time spent in planning meetings, data collection, analysis, writing, and travel. It also includes operating costs such as printing, advertising, and conducting meetings. Any contracts with community-based organizations or local governments for planning and coordination fall into this category, as do needs assessment projects to identify the scope and magnitude of the problem, resources available, gaps in services, and strategies to close those gaps.

Quality assurance – This includes activities to assure conformity to acceptable professional standards and to identify problems that need to be remedied. These activities may occur at the State, sub-State, or program level. Sub-State administrative agency contracts to monitor service providers fall in this category, as do independent peer review activities.

Training (post-employment) – This includes staff development and continuing education for personnel employed in local programs as well as support and coordination agencies, as long as the training relates to substance abuse services delivery. Typical costs include course fees, tuition and expense reimbursements to employees, trainer(s) and support staff salaries, and certification expenditures.

Education (pre-employment) – This includes support for students and fellows in vocational, undergraduate, graduate, or postgraduate programs who have not yet begun working in substance abuse programs. Costs might include scholarship and fellowship stipends, instructor(s) and support staff salaries, and operating expenses.

Program development – This includes consultation, technical assistance, and materials support to local providers and planning groups. Generally these activities are carried out by State and sub-State level agencies.

Research and evaluation – This includes program performance measurement, evaluation, and research, such as clinical trials and demonstration projects to test feasibility and effectiveness of a new approach. These activities may have been carried out by the principal agency of the State or an independent contractor.

Information systems – This includes collecting and analyzing treatment and prevention data to monitor performance and outcomes. These activities might be carried out by the principal agency of the State or an independent contractor.

Form 8c (formerly Form 4c): Resource Development Expenditure Checklist

Now complete the following checklist:

Did your State fund resource development activities from the FY 2008 SAPT Block Grant?

 Yes  No

If yes, show the actual or estimated amounts spent. These amounts may be part of the SAPT Block Grant funds shown on Form 8 in Column A under lines 1 through 5: (1) Substance Abuse Prevention (other than primary prevention) and Treatment (2) Primary Prevention, (3) Tuberculosis Services, (4) HIV Early Intervention Services, and (5) Administration (excluding program/provider level). Note that in describing resource expenditures, you are not limited to line 5 (Administration) funds alone.

List your expenditures in the following three columns: (1) Treatment, showing amounts spent for treatment resource development; (2) Prevention, showing amounts spent for primary prevention resource development; and (3) Additional Combined Expenditures, showing amounts for resource development in situations where you cannot separate out the amounts devoted specifically to treatment or prevention. For column 3, do not include any amounts listed in columns 1 and 2.

Column 4, Total, shows the sum of all expenditures listed on that line in columns 1, 2, and 3. Enter amounts in whole dollars.

Column 1 Column 2 Column 3

Additional

Treatment Prevention Combined Total

 Planning, coordination, $ $ $ $________

and needs assessment

 Quality assurance $ $ $ $________

 Training (post-employment) $ $ $ $________

 Education (pre-employment) $ $ $ $________

 Program development $ $ $ $________

 Research and evaluation $ $ $ $________

 Information systems $ $ $ $________

TOTAL $ $ $ $

Please indicate whether expenditures on resource development activities are actual or estimated.

 Actual  Estimated

3. Form 9 (Note: formerly Form 6) Substance Abuse Entity Inventory

This item documents the activities for which FY 2008 funds were expended by entity. This information is required by CSAT to meet its obligations under the Federal Managers Financial Integrity Act of 1982 (See 31 U.S.C. §3512). The item requires completion of the Substance Abuse Entity Inventory followed by a listing of entities without an Inventory of Substance Abuse Treatment Services (I-SATS) ID that received funds from the FY 2008 SAPT Block Grant to provide substance abuse prevention and treatment services.

The term “entities” is used to cover State and non-State providers, sub-recipient agencies and contractors, grantees, and other programs or entities funded by the State. It includes all direct providers of substance abuse prevention activities and treatment services. Expenditures, including grants and contracts of $25,000 or less for similar purposes and similar areas, may be aggregated into a single line in column 1 if these funds are used by the same State ID/I-SATS ID number.

Form 9 combines a great deal of important information. It identifies how and where each entity used FY 2008 SAPT Block Grant funds and State funds provided through the Single State Agency and how much of the funding went to substance abuse prevention (other than primary prevention) and treatment services, primary prevention activities, HIV early intervention services and services for pregnant women and women with dependent children.

Preparing to complete Form 9

Make a list of all entities that received FY 2008 SAPT Block Grant funds, as well as all entities that received State funds in the period covered in Column D, Form 8. Each entity must have a unique number. You can either number the list consecutively, starting with 1, or use unique State identifier numbers. It does not matter which entity goes first on the list. If an entity has an Inventory of Substance Abuse Treatment Services (I-SATS) ID, place that ID number after the name. If your State funded direct treatment service providers that have not yet been assigned a number, call the contractor for the Office of Applied Studies, SAMHSA, Ms. Alicia McCoy at (703) 807-2329 or contact her by e-mail at AliciaM@smdi.com, to obtain one or complete the list attached to Form 9 (described immediately before Form 9).

Please note that data from the previous year’s Form 9 has been pre-populated in Web BGAS. If an entity was funded in the previous year, it should appear on the list. The Provider Address table from the previous year has also been pre-populated. If an entity was not funded previously, please append to the list. If an entity was not funded for the current reporting year, please delete it from Form 9.

How to complete Form 9

This form should be filled out in two stages. The first stage involves completion of columns 1 through 3. These columns record information about the entity. The second stage involves completion of columns 4 through 7. These columns record information about the use of funds.

Detailed instructions for each stage follow on the next page.

Stage one: Entering entity information (Columns 1 through 3)

Form 9 has been pre-populated with the data submitted in the previous year’s block grant. If an entity was funded previously and not funded in the current reporting year, please delete the entity from Form 9. Please follow the Stage one steps below for adding a new entity to Form 9:

Complete columns 1 through 3 for each new entity.

Column 1: Entity number – This is the number from the entity list you assembled in preparing to complete the form.

Column 2: I-SATS ID – If the entity has an I-SATS ID, enter that number here. Place an “X” in the box if the entity has no I-SATS ID.

Column 3: Area served – This column shows the geographical area served by the entity and involves coded entries. Enter the code you assigned for the sub-State area(s) that the entity serves. Each State may elect how to define its sub-State planning areas. Please append a definition of each sub-State planning area by geographic entity. As an example, if sub-State planning area A comprises four counties, list the county names; if sub-State planning area A is a major metropolitan area and sub-State planning area B comprises the surrounding counties, provide that information. States are encouraged to keep the number of areas to a minimum; however, States must identify at least two sub-State planning areas. These same areas were used in the needs assessment required in Section II of this application.

• An entity may serve the whole State (Statewide) or an entity may serve several areas. For example, entity 1 is a program that serves the entire State. When completing column 3 for this entity, enter a code of ‘99.’

• In Web BGAS, a code of ‘99’ must be entered for any ‘Statewide’ program. No other code will be accepted.

When an entity serves more than one sub-State Planning Areas(s) (SPAs), you will use multiple lines. For example, entity 2 serves two of the SPAs the State designates. You must complete columns 1-3 in one row for the first SPA the entity serves. You must then complete columns 1-3 of a second row for the second SPA the entity serves.

Stage two: Entering funding information (Columns 4 through 7)

These columns describe funding to providers and other entities and how the funding was used for substance abuse prevention activities and treatment services. They require distributing the funding in various ways. Remember that you have to fill out all these columns for every line you completed in stage one. If a column is not applicable to a given line, put a zero in that column. All of the columns, with the exception of column 4, refer to SAPT Block Grant funding only.

Column 4: State funds – Include all State funds spent during the 12-month State expenditure period you designated on Form 1. These funds were reported in column D on Form 8.

• Columns 5 through 7 refer only to the portion of the FY 2008 SAPT Block Grant award that went to either direct or indirect service providers, i.e., entities. Do not include funds spent on State staff or administration.

Column 5: SAPT Block Grant funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services –Enter the amount of funds from the FY 2008 award for this purpose. This includes funds used for alcohol and drug prevention (other than primary prevention) activities and treatment services. This also includes direct services to patients, such as outreach, detoxification, methadone detoxification and maintenance, outpatient counseling, residential rehabilitation including therapeutic community stays, hospital-based care, vocational counseling, case management, central intake, and program administration. Early intervention activities (other than primary prevention), substance abuse treatment and rehabilitation activities, and, if applicable, funds for tuberculosis services should be included as part of column 5. Do not include funds for administration cost in this column.

Column 5a is a subset of the expenditures reported in column 5. For example, a provider may operate an alcohol treatment program targeted toward women. The FY 2008 SAPT Block Grant funding for this provider would be entered twice, first in column 5 and again in column 5a.

Column 5a: SAPT Block Grant funds for Pregnant Women and Women with Dependent Children - Enter the amount of funds from the FY 2008 award for this purpose. This includes treatment for pregnant women and women with dependent children, and women in treatment for prenatal care and childcare. Tuberculosis expenditures are not to be included in the expenditure reports for pregnant women and women with dependent children. Do not include funds for administration cost in this column.

Column 6: SAPT Block Grant funds for primary prevention – Enter the amount of funds from the FY 2008 award for this purpose. This includes funds for education and counseling, and for activities designed to reduce the risk of substance abuse. Do not include funds for administration cost in this column.

Column 7: SAPT Block Grant funds for HIV Early Intervention Services – (Applicable to “Designated States” Only). Enter the amount of funds from the FY 2008 award for this purpose, if applicable. Include funds for pre-test counseling, testing, post-test counseling, and the provision of therapeutic measures to diagnose the extent of deficiency in the immune system to prevent and treat the deterioration of immune system, and to prevent and treat conditions arising from the disease. Include the cost of making referrals to other treatment providers in this item. Do not include funds for administration cost in this column.

Provider Address List to be attached to Form 9

Immediately following the Substance Abuse Entity Inventory form, insert a list of each entity that does not have an I-SATS ID number and provide the entity’s name, street address, city/state (including zip code), and telephone number (including area code). Use the same unique identifying number that you provided on Form 9 in column 1. Please note that the address list has been pre-populated with the addresses submitted in the previous year’s block grant application. If the entity is no longer applicable (i.e. it is no longer funded or it now has an I-SATS ID), delete it from the address list.

Form 9 (formerly Form 6)							Page _____ of _____ pages
SUBSTANCE ABUSE ENTITY INVENTORY (Complete columns 1-3 first. Then complete columns 4-7 for each entry.)
State:				FISCAL YEAR 2008
1. Entity Number	2. I-SATS ID Mark [X] box if no ID	3. Area Served 99-Statewide or Enter Sub-State Area Code (Enter only one SPA Per Line)	4. State Funds (Spent during State Expenditure Period designated on Form 1)	5. SAPT Block Grant Funds for Substance Abuse Prevention (other than primary prevention) and Treatment Services	5.a. SAPT Block Grant Funds for Services for Pregnant Women and Women with Dependent Children	6. SAPT Block Grant Funds for Primary Prevention		7. SAPT Block Grant Funds for Early Intervention Services for HIV (If Applicable)
	[ ]
	[ ]
	[ ]
	[ ]
	[ ]

Form 9a (formerly 6a) Prevention Strategy Report

NOTE: Completion of portions of this form will be optional for a further three years except for column B, which will be required until the phase in year, 2012. During this time, SAMHSA would like to continue to work with the States to refine and finalize this form. SAMHSA is especially interested in developing common definitions for the elements being reported and identifying data sources which may be used to provide these data. States are requested to complete the form as completely as possible (e.g., at least column B and as much more as possible). Provide any comments that will enhance the meaningfulness of the information and aid in improving the completeness, validity and reliability of the data.

The Prevention Strategy Report requires additional information (in accordance with Section 1929 of the PHS Act) about the primary prevention activities conducted by the entities listed on Form 9 column 6. It seeks further information on the specific strategies and activities being funded by the principal agency of the State that addresses the sub-populations at risk for alcohol, tobacco, and other drug (ATOD) use/abuse.

Instructions for completing Form 9a

This form has three columns. The first column seeks information about the sub-populations at risk that are being addressed by the State’s primary prevention program; the second column seeks information about the specific primary prevention strategy(ies) and activities being employed to address each of these risk categories; and the third column seeks information about the total number of providers carrying out each of the activities reported in column B. States are required only to complete column B each year and are strongly encouraged to complete the other 2 columns, where possible. If the State completes optional column A, it need only report on those risk categories that were considered appropriate for its primary prevention program and that were addressed during the reporting year. In completing Column B, the State need only report on those strategies and activities that were considered appropriate and that were conducted during the reporting year.

Column A: Risk categories

States are asked to list each of the sub-populations at risk toward which their primary prevention program is directed. One risk category should be listed on each line. The risk categories and codes are listed below. (SAMHSA recognizes that resource limitations may result in a State’s addressing only those risk categories of greatest concern.) For any risk category not listed below, code the category using codes beginning with “11” and enter a description on the same line. For example, if your State uses three risk categories that do not fit into any of the categories below, enter the code “11” and description of the category. The second category would be coded as “12” and its description beside it. The third category would be coded as “13,” etc.

01 Children of substance abusers

02 Pregnant women/teens

03 Drop-outs

04 Violent and delinquent behavior

05 Mental health problems

06 Economically disadvantaged

07 Physically disabled

08 Abuse victims

09 Already using substances

10 Homeless and/or runaway youth

11 Other, specify

Column B: Strategy/activity

This column describes the primary prevention strategy/activity or strategies and activities used by the principal agency of the State to address each of the risk categories identified in column A and involves coded entries listed below. The definitions for these strategies have been provided in the block grant regulations and are repeated in the instructions for Form 8a. If a State employs strategies not covered by these six categories, please report these under “Other Strategies.”

A State may employ several strategies and activities for each risk category. For example, it may provide both parenting classes and a clearinghouse. Each strategy used to address a risk category should be listed on a separate line.

If you code “Other, specify,” enter the description of the type of strategy/activity on the same line.

The codes for use in column B are:

Information Dissemination

01 Clearinghouse/information resources centers

02 Resource directories

03 Media campaigns

04 Brochures

05 Radio and TV public service announcements

06 Speaking engagements

07 Health fairs and other health promotion, e.g., conferences, meetings, seminars

08 Information lines/Hot lines

09 Other, specify

Education

11 Parenting and family management

12 Ongoing classroom and/or small group sessions

13 Peer leader/helper programs

14 Education programs for youth groups

15 Mentors

16 Preschool ATOD prevention programs

17 Other, specify

Alternatives

21 Drug free dances and parties

22 Youth/adult leadership activities

23 Community drop-in centers

24 Community service activities

25 Outward Bound

26 Recreation activities

27 Other, specify

Problem Identification and Referral

31 Employee Assistance Programs

32 Student Assistance Programs

33 Driving while under the influence/driving while intoxicated education programs

34 Other, specify

Community-Based Process

41 Community and volunteer training, e.g., neighborhood action training, impactor training, staff/officials training

42 Systematic planning

43 Multi-agency coordination and collaboration/coalition

44 Community team-building

45 Accessing services and funding

46 Other, specify

Environmental

51 Promoting the establishment or review of alcohol, tobacco, and drug use policies in schools

52 Guidance and technical assistance on monitoring enforcement governing availability and distribution of alcohol, tobacco, and other drugs

53 Modifying alcohol and tobacco advertising practices

54 Product pricing strategies

55 Other, specify

Other prevention activities

For any prevention activity not included in the list above, code the activity using codes beginning with “71” and enter a description on the same line. For example, if your State uses three unique primary prevention activities that do not fit into any of the categories above, enter the code “71” in column B and description of the activity. The second activity would be coded as “72” and its description would be entered on a separate line. The third strategy would be coded as “73,” etc.

Column C: Providers

This column records the number of providers performing each of the activities identified in Column B. Providers are those entities reported on Form 6 of the application as having expended primary prevention set-aside funds.

Enter the total number of providers that employ a specific strategy/activity to address the prevention needs of a risk category before proceeding to the next line.

Form 9a

Prevention Strategy Report Risk-Strategies
State:
Column A (Risks)	Column B (Strategies)	Column C (Providers)
Children of Substance Abusers [1]
Pregnant Women / Teens [2]
Drop-Outs [3]
Violent and Delinquent Behavior [4]
Mental Health Problems [5]
Economically Disadvantaged [6]
Physically Disabled [7]
Abuse Victims [8]
Already Using Substances [9]
Homeless and/or Runaway Youth [10]
Other, Specify [11]

4. Forms 10a and 10b (Note: formerly Forms 7a and 7b)

Services Utilization Data: How to complete these forms

These items require the completion of the Treatment Utilization Matrix (Form 10a) and the matrix for Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services (Form 10b).

These Forms are intended to capture the unduplicated count of persons with initial admissions to an episode of care (as defined in the Treatment Episode Data System standards) during the 12-month State expenditure period you designated on Form 1. Note that in Form 10a, the number of persons served reported in column B is a subset of the number of admissions reported in column A. Numbers admitted seeks to capture information by level of care on the number of initial admissions to an episode of care during the 12-month State expenditure period you designated on Form 1. Clients served during the State expenditure period is a subset of Column A requiring the State to count individuals only once for each level of care even if they terminate and are readmitted to that level of care during the 12-month time period. A client is defined as an individual served even if the only service they receive is admission.

In Form 10b, each client with an initial admission or subsequent admissions reported on Form 10a, column A to any level of care during the State expenditure period is to be reported only once. Note that the Form 10a rows are not to be totaled nor would that total be expected to equal the total of Form 10b because a person may be served at more than one level of care and would be counted more than once on Form 10a.

Form 10a documents the levels and amounts of care purchased Statewide during the 12-month State expenditure period you designated on Form 1, by the principal agency of the State administering the block grant. Include all care purchased with public dollars, regardless of the source of funds.

How to Complete Form 10a (Treatment Utilization Matrix)

The rows on Form 10a define levels of care. The definitions are as follows:

DETOXIFICATION (24-HOUR CARE)

Row 1: Hospital inpatient – Twenty-four hour/day medical acute care services for detoxification for persons with severe medical complications associated with withdrawal.

Row 2: Free-standing residential – Twenty-four hour/day services in a non-hospital setting that provide for safe withdrawal and transition to ongoing treatment.

REHABILITATION/RESIDENTIAL

Row 3: Hospital inpatient - Twenty-four hour/day medical care (other than detoxification) in a hospital facility in conjunction with treatment services for alcohol and other drug abuse and dependency.

Row 4: Short-term (up to 30 days) – Short-term residential, typically 30 days or less of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency.

Row 5: Long-term (over 30 days) - Long-term residential, typically over 30 days of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency (may include transitional living arrangements such as halfway houses).

AMBULATORY (OUTPATIENT)

Row 6: Outpatient – Treatment/recovery/aftercare or rehabilitation services provided where the patient does not reside in a treatment facility. The patient receives drug abuse or alcoholism treatment services with or without medication, including counseling and supportive services. Day treatment is included in this category. This also is known as nonresidential services in the alcoholism field.

Row 7: Intensive outpatient – Services provided to a patient that last two or more hours per day for three or more days per week.

Row 8: Detoxification – Outpatient treatment services rendered in less than 24 hours that provide for safe withdrawal in an ambulatory setting (pharmacological or non-pharmacological).

Row 9: Opioid Replacement Therapy - Report the number of clients for whom it was planned to use opioid replacement therapy during their course of treatment.

Reporting on Form 10a Levels of Care (Treatment Utilization Matrix)

All numbers should reflect treatment services provided to clients with an initial admission to an episode of care during the 12-month State Expenditure Period that you designated on Form 1. Your State may not have funded all levels of care. If any row is not applicable, enter zeroes in the appropriate columns.

States must report treatment utilization data in columns A and B and are requested to report data in columns C, D, and E if possible.

Column A: Report the total number of initial admissions to an episode of care for each of the nine levels of care during the 12-month State Expenditure Period designated on Form 1. Each re-admission of a client that occurs during the applicable 12-month time frame would be counted.

Column B: Report the unduplicated number of persons served within the set of persons who were admitted during the 12-month period specified on Form 1. Note that column B is a subset of column A. Clients served during the State Expenditure Period are counted only once in each applicable level of care, even if they terminate and are readmitted during the 12-month time period.

Column C: Report the mean cost per person served for each of the nine levels of care. The mean cost is the total cost, including operating and capital costs, divided by the number of persons served. If your program offers services to family members and others besides the client, then count only those persons who actually have a treatment record and have received counseling or treatment services. For example, children would not be counted if they receive only daycare within a women’s program that is providing treatment to their mother.

Column D: Report the median cost per person for each of the nine levels of care.

Column E: Report the standard deviation of cost per person for each of the nine levels of care.

Form 10a (formerly Form 7a) Treatment Utilization Matrix
	Dates of State expenditure period from _______ to _______ (Same as Form 1)
STATE:	Number of Admissions ≥ Number of Persons Served		Costs per Person
LEVEL OF CARE	A. Number of Admissions	B. Number of Persons Served	C. Mean Cost of Services	D. Median Cost of Services	E. Standard Deviation of Cost
Detoxification (24-Hour Care)
1. Hospital Inpatient			$	$	$
2. Free-Standing Residential			$	$	$
Rehabilitation/Residential
3. Hospital Inpatient			$	$	$
4. Short-term (up to 30 days)			$	$	$
5. Long-term (over 30 days)			$	$	$
Ambulatory (Outpatient)
6. Outpatient			$	$	$
7. Intensive Outpatient			$	$	$
8. Detoxification			$	$	$
9. Opioid Replacement Therapy			$	$	$

Reporting on Form 10b [formerly Form 7b] (Number of Persons Served [Unduplicated Count] for Alcohol and Other Drug Use in State-Funded Treatment Services)

In Form 10b, each client initiating care at any level of service described in Form 10a during the State Expenditure Period is to be reported according to age, sex, racial and ethnic categories. In addition, this form also documents the number of clients who were pregnant. A separate cell is also provided to capture data on clients served in this reporting period but admitted in a prior period who have received services as identified in Form 10a. Finally, the last cell is made available to capture estimates or actual counts of any persons only served outside of the levels of care delineated in Form 10a. This would include persons that only received services such as brief intervention, early intervention or various recovery support treatment services (but not primary prevention services). For example, persons may have never been admitted to one of the standard levels of care but were provided treatment services, as defined by the State. However their services were not captured or reported by State TEDS data. The race and ethnicity are the categories required by the October 30, 1997 revision of OMB Statistical Policy Directive No. 15: Race and Ethnic Standards for Federal Statistics and Administrative Reporting (http://www.whitehouse.gov/omb/fedreg/ombdir15.html).

Form 10b covers persons admitted and served through care purchased statewide by the principal agency of your State that administered the block grant during the 12-month State Expenditure Period you designated on Form 1. Include all care purchased with public dollars, regardless of the source of funds.

Column A: Report the total number of persons served Statewide (unduplicated count) for each age group in rows 1 through 5, with the sum of persons in all age groups shown in row 6. Row 7 is the total number of women who were pregnant.

Columns B through H: Report the number of persons served (unduplicated count) for rows 1 through 5 across sex and race/ethnicity columns B through H. For the “total” row 6, enter the number of persons served for the total group captured within each column. The total of columns B through H should equal the total reported in Column A.

Columns I and J: Report the number of persons by sex and age who are either (I) not Hispanic or Latino or (J) Hispanic or Latino. Note that the total of Columns I and J should also equal the total reported in Column A. In row 7, the total number of pregnant women in columns I and J, as well as the total number in columns B through H, should both equal the total in Column A.

• Did the values reported by your State on Forms 10a and 10b come from a client-based system(s) with unique client identifiers?

 Yes  No

In the second section of Form 10b, report the Numbers of Persons Served during this period who were admitted prior to the current 12 month reporting period but were not counted in the first section of Form 10b, and the number of persons served only outside of the levels of care listed on Form 10a.

Form 10b (formerly Form 7b)

Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State-Funded Services by Age, Sex, and Race/Ethnicity

State:

Sex and Race/Ethnicity

Age

A. TOTAL

B. WHITE

C. BLACK OR AFRICAN AMERICAN

D. NATIVE HAWAIIAN/ OTHER PACIFIC ISLANDER

E. ASIAN

F. AMERICAN INDIAN / ALASKA NATIVE

G. MORE THAN ONE RACE REPORTED

H. UNKNOWN

I. NOT HISPANIC OR LATINO

J. HISPANIC OR LATINO

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

1. 17 & Under

2. 18 - 24

3. 25 – 44

4. 45 – 64

5. 65 and over

6. Total

7. Pregnant Women

Numbers of Persons Served who were admitted in a Period Prior to the 12 month reporting Period
Number of persons served outside of th elevels of care described on Form 10a

5. Maintenance of Effort (MOE) Tables: (Single State Agency (SSA) MOE, TB MOE, HIV MOE, and Women’s Base and Expenditures).

Description of Calculations

If revisions or changes are necessary to prior years’ description of the following, please provide: a brief narrative describing the amounts and methods used to calculate the following: (a) the base for services to pregnant women and women with dependent children as required by 42 U.S.C. §300x-22(b)(1); and, for 1994 and subsequent fiscal years report the Federal and State expenditures for such services; (b) the base and Maintenance of Effort (MOE) for tuberculosis services as required by 42 U.S.C. §300x-24(d); and, (c) for designated States, the base and MOE for HIV early intervention services as required by 42 U.S.C.§300x-24(d) (See 45 C.F.R. §96 122(f)(5)(ii)(A)(B)(C)).

Instructions and Forms for completing Tables I through IV

These forms are pre-populated in WEB BGAS with data reported in prior years. If actual expenditures were not reported in the previous year, the State may request to remove the pre-populated data by clicking the button on the relevant MOE form in Web BGAS.

Table I

Table I is a Maintenance of Effort (MOE) table tracking expenditures for authorized activities to prevent and treat substance abuse flowing through the SSA during each State fiscal year (SFY). (See 42 U.S.C. §300x-30 and 45 C.F.R. §96.134).

• Enter expenditures for SFYs 2008, 2009, and 2010 in the corresponding boxes (B1, B2 and B3) in column B. (The State may, with approval from the Secretary, exclude from the calculation non-recurring expenditures awarded to the SSA for a specific purpose for SFY 2001 and subsequent fiscal years, see below).

• Compute the average of the amounts in B1 and B2 by adding the two amounts and dividing by 2. Enter the resulting average in Box C2.

The MOE for State fiscal year (SFY) 2010 is met if the amount in Box B3 is greater than or equal to the amount in Box C2 assuming the State complied with MOE requirements in these previous years.

The State may request an exclusion of certain non-recurring expenditures for a singular purpose from the calculation of the MOE, provided it meets SAMHSA approval based on review of the following information:

Did the State have any non-recurring expenditures for a specific purpose which were not included in the MOE calculation?

Yes____ No ___

If yes, specify the amount and the State fiscal year ___________.

Did the State include these funds in previous year MOE calculations? Yes___ No___.

When did the State submit an official request to the SAMHSA Administrator to exclude these funds from the MOE calculations? mm/dd/yyyy

Table I

Total Single State Agency (SSA) Expenditures for Substance Abuse

Period (A)	Expenditures (B)	B1 (2008) + B2 (2009) 2 (C)
SFY 2008 (1)
SFY 2009 (2)
SFY 2010 (3)

Are the expenditure amounts reported in Columns B “actual” expenditures for the State fiscal years involved?

FY 2008 Yes No

FY 2009 Yes No

FY 2010 Yes No

If estimated expenditures are provided, please indicate when “actual” expenditure data will be submitted to SAMHSA: mm/dd/yyyy

Table II

Table II is a MOE table tracking all Statewide, non-Federal funds spent on Tuberculosis (TB) services to substance abusers in treatment during each SFY.

1. Enter State funds spent on TB services for SFY 1991 in box A1 of Table II (Base).

2. Enter the actual or estimated percent of these funds that was spent on substance abusers in treatment for SFY 1991 in box B1 of Table II (Base).

3. Divide this percent by 100 to change it to a decimal.

4. Multiply the amount in box A1 by the decimal value of the amount in box B1. Enter the resulting amount in box C1 of Table II (Base).

5. Follow the same procedure for row 2 in Table II (Base) as was done in row 1.

6. Compute the average of the amounts in boxes C1 and C2. Enter the resulting average (MOE Base) in box D2.

7. Follow the above procedure (steps 1 through 4) for row 3 of Table II (Maintenance).

The TB MOE is met in State fiscal year 2010, if the amount in box C3 is equal to or greater than the amount in box D2 of the top chart.

Table II (BASE)

Statewide Non-Federal Expenditures for Tuberculosis Services to Substance Abusers in Treatment

Period	Total of All State Funds Spent on TB Services (A)	% of TB Expenditures Spent on Clients who were Substance Abusers in Treatment (B)	Total State Funds Spent on Clients who were Substance Abusers in Treatment (AxB) (C)	Average of Column C1 and C2 C1 + C2 2 (MOE BASE) (D)
SFY 1991 (1)
SFY 1992 (2)

Table II (MAINTENANCE)

Statewide Non-Federal Expenditures for Tuberculosis Services to Substance Abusers in Treatment

Period	Total of All State Funds Spent on TB Services (A)	% of TB Expenditures Spent on Clients who were Substance Abusers in Treatment (B)	Total State Funds Spent on Clients who were Substance Abusers in Treatment (AxB) (C)
SFY 2010 (3)

Table III

Table III is an MOE table that tracks all non-Federal funds spent on early intervention services for HIV provided to substance abusers in treatment at the site at which they receive substance abuse treatment during each SFY. Web BGAS will provide you with the appropriately configured table. If you plan to use the MS Word version, you must complete the generic table using the instructions below.

COMPLETE TABLE III ONLY IF YOUR STATE WAS A DESIGNATED STATE

1. If you are a designated State, enter the most recent Federal fiscal year in which your State became a designated State.

2. Enter State funds spent on early intervention services for HIV during the two years prior to the year you have identified in response to Number 1 above in boxes A1 and A2 in the left chart.

3. Compute the average of the amounts in boxes A1 and A2. Enter the resulting average (MOE Base) in box B2.

4. Enter State funds spent on early intervention services for HIV for State fiscal year 2010 box A3 of the right chart (MAINTENANCE).

The HIV MOE is met in State fiscal year 2010, if the amount in box A3 in the right chart (MAINTENANCE), is equal to or greater than the amount in box B2 of the corresponding left chart (MOE Base).

Table III (BASE and MAINTENANCE)

Statewide Non-Federal Expenditures for HIV Early Intervention Services to Substance Abusers in Treatment (Table III)

Enter the year in which your State last became a designated State, Federal Fiscal Year____. Enter the 2 prior years’ expenditure data in A1 and A2. Compute the average of the amounts in boxes A1 and A2. Enter the resulting average (MOE Base) in box B2.

(BASE) (MAINTENANCE)

Period	Total of All State Funds Spent on Early Intervention Services for HIV (A)	Average of Columns A1 and A2 A1+A2 2 (MOE Base) (B)		Period	Total of All State Funds Spent on Early Intervention Services for HIV (A)
(1) SFY ____
(2) SFY____				(3) SFY 2010

Table IV

Table IV tracks the total (block grant and State) expenditures for services to substance using pregnant women and women with dependent children during each fiscal year.

1. For 1994, enter the base in column A.

2. For Federal fiscal year 1995 and subsequent fiscal years the States must maintain expenditures for services for pregnant women and women with dependent children at a level that is not less than the FY 1994 expenditures; however, the expenditures may be any combination of SAPT Block Grant and State general revenue (including the State’s contribution to Medicaid). Report all actual expenditures for 2008, 2009, and 2010 in column B.

Table IV (MAINTENANCE)

Expenditures for Services to Pregnant Women

and Women with Dependent Children

Period	Total Women’s BASE (A)	Total Expenditures (B)
1994
2008
2009
2010
Enter the amount the State plans to expend in 2011 for services for pregnant women and women with dependent children (amount entered must be not less than amount entered in Table IV Maintenance - Box A (1994)): $ __________

SECTION IVa

TREATMENT PERFORMANCE MEASURES

INSTRUCTIONS

TREATMENT MEASURES

Data is requested on the following forms:

Form T1 – Employment/Education Status

Form T2 – Living Status

Form T3 – Criminal Justice Involvement

Form T4 – Alcohol Use

Form T5 – Other Drug Use

Form T6 – Social Support of Recovery

Form T7 – Retention

Page Intentionally Left Blank

GENERAL INSTRUCTIONS FOR FORMS T1-T7:

TEDS AS SOURCE OF DATA STANDARDS

To CLARIFY: State staff who are unclear about how data are to be captured and reported are directed to refer to the Treatment Episode Data Specifications referenced in each of the Interim Data Standards accompanying T1-T5 data Forms. See http://wwwdasis.samhsa.gov/dasis2/teds.htm.

Variances between TEDS standards and the Interim Data Standards should be clearly described for each measure as requested in instructions 4, 5 and 6 as well as on page 3 of the application guidance. States are encouraged to provide data notes in the footnote function of Web BGAS whenever warranted especially when there is variance from the specified TEDS or Interim Standards.

SAMHSA is interested in demonstrating program accountability and efficacy through the National Outcome Measures (NOMs). The NOMs are intended to document the performance of Federally supported programs and systems of care. The following set of instructions and forms are intended to collect States’ NOMs or treatment performance measures. States using the Web Block Grant Application System (Web BGAS) may either elect to use pre-populated data forms based on analyses of their Treatment Episode Data Set (TEDS) or may complete these forms independently. The State’s use of such data should then be discussed in the accompanying narratives addressing State Performance Management and Leadership and Provider Involvement.

It is understood that, at the current time, not all States have the infrastructure in place that supports the reporting of such data. If States are not currently reporting such data, States must communicate their current progress on their corrective action plans to report on the SAPT Block Grant supported program performance measures, a clear explanation of the State’s problem in obtaining the data, what barriers exist and the State time-framed plan to collect and report this data. Such information is critical to inform future activities leading towards full implementation of the performance-based SAPT Block Grant Program.

If the State is using Web BGAS, the State may elect to have the treatment performance measure forms automatically pre-populated with data already submitted to SAMHSA through the Office of Applied Studies’ (OAS) Drug Abuse Services Information System (DASIS), Treatment Episode Data Set (TEDS), State Outcome Measurement and Monitoring System (SOMMS). Web BGAS provides instructions for viewing the State’s data and for electing to have the State’s performance measures pre-populated.

The specifications for pre-populating the application for treatment NOMS data previously submitted SAMHSA by participating in the DASIS/TEDS/SOMMS program are provided below:

• Pre-populated data will be reported separately for the four major levels of care defined in the SAMHSA TEDS program (i.e., outpatient, intensive outpatient, short- and long- term residential);

• All records from providers that do not receive public funding will be excluded to the extent that the State identifies them to SAMHSA; and

• All change measures will be directly calculated by subtraction representing direct change.

If a State elects to pre-populate Performance Measure tables T1-T5, and T7, Web BGAS will pre-populate all tables for which SAMHSA’s Office of Applied Studies has received adequate data from the State through DASIS/TEDS/SOMMS. These pre-populated tables will be used for the purposes of completing the section as well as for external reporting. States electing to use pre-populated data are encouraged to add footnotes concerning their pre-populated data tables describing their State’s TEDS data set.

If a State chooses to complete these tables independently, the following instructions should be used.

1. Include all “Primary Clients” who received services from treatment programs that received some or all of their funding from the Substance Abuse Prevention and Treatment Block Grant. Do not include family members or other persons collaterally involved in the clients’ treatment. Include only persons actually admitted to treatment, excluding those who received detoxification, outreach, early intervention or assessment/Central Intake services but who did not enter treatment. In addition to completing the T tables as described by the directions above, a State may wish to report on specific modalities or populations separately such as outpatient, residential and opioid replacement therapy or treatment completers versus non-completers. The State is asked to clearly identify how and why such distinctions are made. The State should discuss how it addressed tracking clients receiving opioid replacement therapy/pharmacotherapy in their State and provide a description in the State Description of Data Collection form.

2. Report data for the most recent year for which the data are available at the time the application is submitted on Forms T1-T7. Enter the 12 month period reported in each Form in the space provided.

3. Report data on all clients who have a discharge record in the reporting year. All clients with treatment periods that ended in the reporting year (i.e., clients who did not receive subsequent treatment in 30 days) should have a discharge record.

4. Please complete each form if possible. If a State is currently under a NOMs corrective action plan to ensure compliance with this reporting requirement, the State must provide an updated corrective action plan describing their current capacity to report on the proposed SAPT Block Grant supported program performance measures, a clear explanation of the State’s problem in obtaining the data, what barriers exist and the State time-framed plan to collect and report this data.

5. Forms T1-T6 collect data on the number and percent of clients for the characteristics of interest (i.e., employment/education status, stability of housing, etc.) at admission and discharge. If possible, the State should report based on treatment episode. In episode-based reporting, admission is defined as occurring on the first date of service in a program/service delivery unit prior to which no services have been received from any program/service delivery unit for 30 days. Discharge is defined as occurring on the last date on which the client received service from a program/service delivery unit, subsequent to which the client received no services from any program/service delivery unit for 30 days. For example, a client may present for detoxification 29 days after being discharged from an intensive outpatient program. If possible, that client’s treatment in detoxification and subsequent levels of care, if any, should be linked to the prior service(s) record(s) up to the point where a client had an uninterrupted 30 day period in which no services were received. If a client presented for treatment 32 days after being discharged from a previous treatment service, a new episode of care would begin.

If a State is unable to report on an episode basis, it should report the basis it has used for producing the reported data. For example, the State may only be able to report data based on Modalities/Levels of Care. In this case, the State should also discuss the specific approach used to define admission and discharge within this framework.

6. For Forms T1-T6, please respond to the questions related to data source, e.g., how admission and discharge basis are defined, how admission and discharge data are collected, how admission and discharge data are linked, and whether or not the State is able to collect such data.

INSERT OVERALL NARRATIVE:

The State should address as many of these questions as possible and may provide other relevant information if so desired. Responses to questions that are already provided in other sections of the application (e.g., planning, needs assessment) should be referenced whenever possible.

State Performance Management and Leadership

Describe the Single State Agency’s capacity and capability to make data driven decisions based on performance measures. Describe any potential barriers and necessary changes that would enhance the SSA’s leadership role in this capacity.

Describe the types of regular and ad hoc reports generated by the State and identify to whom they are distributed and how.

If the State sets benchmarks, performance targets or quantified objectives, what methods are used by the State in setting these values?

What actions does the State take as a result of analyzing performance management data?

If the SSA has a regular training program for State and provider staff that collect and report client information, describe the training program, its participants and frequency.

Do workforce development plans address NOMs implementation and performance-based management practices?

Does the State require providers to supply information about the intensity or number of services received?

FORM T1 – TREATMENT PERFORMANCE MEASURE

EMPLOYMENT\EDUCATION STATUS (From Admission to Discharge)

Most recent year for which data are available: _____________

Employment\Education Status – Clients employed or student (full-time or part-time) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients employed or student (full-time and part-time) [numerator]
Total number of clients with non-missing values on employment\student status [denominator]
Percent of clients employed or student (full-time and part-time)

Performance Measure Data Collection

Interim Standard T1 – Change in Employment\Education Status

(from Admission to Discharge)

GOAL	To improve the employment\student status of persons treated in the State’s substance abuse treatment system.
MEASURE	The change in all clients receiving treatment who reported being employed or being a student (including part-time) at discharge.
DEFINITIONS	Change in all clients receiving treatment who reported being employed or being a student (including part-time) at admission and discharge.

For example:

Employment\Education Status - Clients employed or student (full-time and part-time) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients employed or student (full-time and part-time) [numerator] [e.g., TEDS MDS 13; codes 01 and 02 and SUDS 12, item 02]	12,876	13,598
Total number of clients with non-missing values on employment or student status [denominator] [e.g., any valid TEDS codes MDS 13 01-04 and SUDS 12 02, excluding MDS 13, 97-98 and SUDS 12, 01, 03-06, 97-98]	26,208	26,208
Percent of clients employed or student (full-time and part-time)	49.1%	51.9%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to Objective 26-8 (Developmental): Reduce the cost of lost productivity in the workplace due to alcohol and drug use.
INTERIM STANDARD FOR DATA COLLECTION	Data related to employment and student status should be collected using the relevant Treatment Episode Data Set (TEDS) element at admission and discharge. States report on number and proportion of clients employed from the 30 days preceding admission to treatment, to the 30 days preceding discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. “Employed” includes those employed full time (35 or more hours per week) and part time (less than 35 hours per week). Exclude those not in the labor force, except students.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data (e.g., TEDS, State-based information system, etc.).
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T1

State Description of Employment\Education Status Data Collection (Form T1)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Employment\Education Data Collection (Form T1): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T1 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify ___________________
EPISODE OF CARE	How is the admission/discharge basis defined for table T1 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T1 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table T1(select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing employment\student status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T2–TREATMENT PERFORMANCE MEASURE

STABILITY OF HOUSING (From Admission to Discharge)

Most recent year for which data are available: _____________

Clients living in a stable living situation (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients living in a stable situation [numerator]
Total number of clients with non-missing values on living arrangements [denominator]
Percent of clients in a stable living situation

Performance Measure Data Collection

Interim Standard T2 – Change in Stability of Housing (Living Status)

GOAL	To improve living conditions of persons treated in the State’s substance abuse treatment system.
MEASURE	The change of all clients receiving treatment who reported a stable living situation at discharge.
DEFINITIONS	Change of all clients receiving treatment who reported a stable living situation at discharge equals the clients reporting being in a stable living situation at admission subtracted from the clients reporting being in a stable living situation at discharge.

For example:

Stability of Housing – Clients reporting being in a stable living situation (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients in a stable living situation [numerator] [e.g., TEDS supplemental codes SUDS 08; response items 02 and 03]	28,300	28,702
Total number clients with non-missing values on living arrangements [denominator] [e.g., TEDS supplemental codes SUDS 08; 01-03 x 97-98]	29,033	29,033
Percent of clients in stable living situation	97.5	98.9%

HEALTHY PEOPLE 2010 OBJECTIVES	No Related Objectives
INTERIM STANDARD FOR DATA COLLECTION	Data related to living status should be collected using the relevant Treatment Episode Data Set (TEDS) element at admission and discharge. The reported measure will reflect differences in persons reporting a stable living situation at admission to treatment, and at discharge. States should track client-level data by matching admission to discharge records through a unique statewide client ID. For the purposes of this analysis, persons defined in TEDS as homeless will not be counted as persons living in a stable living situation. TEDS defines homeless as clients with no fixed address; includes shelters. Dependent living (at risk for being homeless) is defined as clients living in a supervised setting such as a residential institution, halfway house or group home.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data (e.g., TEDS, State-based information system, etc.).
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T2

State Description of Stability of Housing (Living Status) Data Collection (Form T2)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Stability of Housing (Living Status) Data Collection (Form T2): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T2 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify________
EPISODE OF CARE	How is the admission/discharge basis defined for table T2 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T2 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table T2 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing living status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T3– TREATMENT PERFORMANCE MEASURE

CRIMINAL JUSTICE INVOLVEMENT (From Admission to Discharge)

Most recent year for which data are available: _____________

Clients without arrests (any charge) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of Clients without arrests [numerator]
Total number of clients with non-missing values on arrests [denominator]
Percent of clients without arrests

Performance Measure Data Collection

Interim Standard T3 – Change in Criminal Justice Involvement

GOAL	To improve arrest-free status of persons treated in the State’s substance abuse treatment system.
MEASURE	The change in persons without arrests in the last 30 days at discharge for all clients receiving treatment.
DEFINITIONS	Change in persons without arrests in the last 30 days at discharge for all clients receiving treatment equals clients who were not arrested in the 30 days prior to admission subtracted from clients who were not arrested in the last 30 days at discharge. An arrest is any arrest.

For Example:

Criminal Justice Involvement - Clients without arrests (any charge) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients without arrests at admission vs. discharge [numerator] [see TEDS manual – SUDS 16]	26,134	27,300
Total number of Admission and Discharge clients with non-missing values on arrests [denominator] [see current TEDS manual – SUDS 16]	27,789	27,789
Percent of clients without arrests at admission vs. discharge	94.0%	98.2%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to Objective 26-8 (Developmental): Reduce the cost of lost productivity in the workplace due to alcohol and drug use. For drug abuse, most (56 percent) of the estimated productivity losses were associated with crime, including incarcerated perpetrators (26 percent) of drug-related crime.
INTERIM STANDARD FOR DATA COLLECTION	States will collect information on the clients without any arrests (a dichotomous response item: arrested – yes/no) in the 30 days preceding admission to treatment and the percentage of clients without any arrests in the 30 days prior at discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. Any client who has no arrest counts (not charges) in the past 30 days, is included in this measure.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data. (e.g., TEDS, State-based information system, etc.)
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T3

State Description of Criminal Involvement Data Collection (Form T3)

STATE CONFORMANCE TO INTERIM STANDARD	States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T3 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify ___________________
EPISODE OF CARE	How is the admission/discharge basis defined for table T3 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________ _________________________________________________________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T3 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table T3 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing criminal justice involvement status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T4– PERFORMANCE MEASURE

CHANGE IN ABSTINENCE – ALCOHOL USE (From Admission to Discharge)

Most recent year for which data are available: _____________

Alcohol Abstinence – Clients with no alcohol use (all clients regardless of primary problem) (use Alcohol Use in last 30 days field) at admission vs. discharge.	Admission Clients (T1)	Discharge Clients (T2)
Number of clients abstinent from alcohol [numerator]
Total number of clients with non-missing values on “used any alcohol” variable [denominator]
Percent of clients abstinent from alcohol
(1) If State does not have a "used any alcohol" variable, calculate instead using frequency of use variables for all primary, secondary, or tertiary problem codes in which the coded problem is Alcohol (e.g. ,TEDS Code 02)

Performance Measure Data Collection

Interim Standard T4 – Change in Abstinence - Alcohol Use

GOAL	To reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change in all clients receiving treatment who reported abstinence at discharge.
DEFINITIONS	Change in all clients receiving treatment who reported abstinence at discharge equals clients reporting abstinence at admission subtracted from clients reporting abstinence at discharge.

For example:

Alcohol Abstinence - Clients with no alcohol use (all clients regardless of primary problem) (use Alcohol Use in last 30 days field) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients abstinent from alcohol [numerator] [e.g., TEDS code 01 - no use]	13,530	19,436
Total number of clients with non-missing values on "used any alcohol" variable [denominator] [e.g., TEDS codes 01-05, x 96-98]	27,658	27,658
Percent of clients abstinent from alcohol	48.9%	70.3%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to: Objective 26-9: Increase the age and proportion of adolescents who remain alcohol and drug free; Objective 26-10: Reduce past month use of illicit substances; Objective 26-11: Reduce the proportion of persons engaging in binge drinking of alcoholic beverages; and Objective 26-12: Reduce average annual alcohol consumption.
INTERIM STANDARD FOR DATA COLLECTION	Data related to alcohol use should be collected using the relevant Treatment Episode Data Set (TEDS) elements at admission and discharge to identify primary, secondary, and tertiary alcohol use and the associated frequency of use data. The reported measure will reflect differences in abstinence in the 30 days preceding admission to AOD treatment, and in the 30 days prior to discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. Abstinence from alcohol use is defined as no past month use of alcohol.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data. (e.g., TEDS, State-based information system, etc.)
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T4

State Description of Alcohol Use Data Collection (Form T4)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Alcohol Use Data Collection (Form T4): State should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T4 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________
EPISODE OF CARE	How is the admission/discharge basis defined for table T4 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T4 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table T4 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing abstinence - alcohol use status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T5– PERFORMANCE MEASURE

CHANGE IN ABSTINENCE -- OTHER DRUG USE (From Admission to Discharge)

Most recent year for which data are available: _____________

Drug Abstinence – Clients with no drug use (all clients regardless of primary problem) (use Any Drug Use in last 30 days field) at admission vs. discharge.	Admission Clients (T1)	Discharge Clients (T2)
Number of Clients abstinent from illegal drugs [numerator]
Total number of clients with non-missing values on “used any drug” variable [denominator]
Percent of clients abstinent from drugs
(2) If State does not have a "used any drug" variable, calculate instead using frequency of use variables for all primary, secondary, or tertiary problem codes in which the coded problem is Drugs (e.g., TEDS Codes 03-20)

Performance Measure Data Collection

Interim Standard T5 – Change in Abstinence – Other Drug Use

GOAL	To reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change of all clients receiving treatment who reported abstinence at discharge.
DEFINITIONS	Change in all clients receiving treatment who reported abstinence at discharge equals clients reporting abstinence at admission subtracted from clients reporting abstinence at discharge.

For example:

Drug Abstinence - Clients with no drug use (all clients regardless of primary problem) (use Any Drug Use in last 30 days field) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients abstinent from illegal drugs [numerator] [e.g., TEDS code 01 - no use]	18,741	21,707
Total number of Admission and Discharge clients with non-missing values on "used any drug" variable [denominator] [e.g., TEDS codes 01-05, x 96-98]	27,668	27,668
Percent of clients abstinent from drugs	67.7%	78.5%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to Objective 26-10: Reduce past-month use of illicit substances.
INTERIM STANDARD FOR DATA COLLECTION	Data related to other drug use should be collected using the relevant Treatment Episode Data Set (TEDS) elements at admission and discharge to identify primary, secondary, and tertiary other drug use and the associated frequency of use data. The reported measure will reflect differences in abstinence in the 30 days preceding admission to AOD treatment, and in the 30 days prior to discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique statewide client ID. Abstinence from other drug use is defined as no past month use of other drugs.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data. (e.g., TEDS, State-based information system, etc.)
DATA ISSUES	State instruments may differ from TEDS definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T5

State Description of Other Drug Use Data Collection (Form T5)

STATE CONFORMANCE TO INTERIM STANDARD	State Description of Other Drug Use Data Collection (Form T5): States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T5 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test or other biological assay □ collateral source □ Administrative data source □ Other Specify ___________________
EPISODE OF CARE	How is the admission/discharge basis defined for table T5 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T5 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table T5 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing abstinence – drug use status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T6 – PERFORMANCE MEASURE

CHANGE IN SOCIAL SUPPORT OF RECOVERY (From Admission to Discharge)

Most recent year for which data are available: _____________

Social Support of Recovery – Clients participating in self-help groups (e.g., AA, NA, etc.) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients participating in self-help (AA NA meetings attended, etc.) [numerator]
Total number of Admission and Discharge clients with non-missing values on self-help activities [denominator]
Percent of clients participating in self-help activities

Performance Measure Data Collection

Interim Standard T6 – Change in Social Support of Recovery

GOAL	To improve clients’ participation in social support of recovery activities to reduce substance abuse to protect the health, safety, and quality of life for all.
MEASURE	The change of all clients receiving treatment who reported participation in self-help (mutual support) groups at discharge.
DEFINITIONS	Change of all clients receiving treatment who reported participation in self-help in the 30 days preceding admission to substance abuse treatment, compared to such participation in the 30 days prior to discharge (or since admission if less than 30 days).

For example:

Social Support of Recovery - Clients participating in self-help groups, (e.g., AA NA etc) (prior 30 days) at admission vs. discharge	Admission Clients (T1)	Discharge Clients (T2)
Number of clients with one or more such activities (AA NA meetings attended, etc.) [numerator] [no TEDS equivalent, see SAIS item.]	6,701	11,021
Total number of Admission and Discharge clients with non-missing values on self-help activities [denominator] [no TEDS equivalent, see ATR RFA Appendix C.]	23,106	23,106
Percent of clients participating in self-help activities	29.0%	47.7%

HEALTHY PEOPLE 2010 OBJECTIVES	Related to: Objective 26-9: Increase the age and proportion of adolescents who remain alcohol and drug free; Objective 26-10: Reduce past month use of illicit substances; Objective 26-11: Reduce the proportion of persons engaging in binge drinking of alcoholic beverages; and Objective 26-12: Reduce average annual alcohol consumption.
INTERIM STANDARD FOR DATA COLLECTION	Data should be collected using the elements as follows: Participation in social support of recovery activities is defined as attending self-help group meetings. The reported measure will reflect differences in such participation in the 30 days preceding admission to substance abuse treatment, and such participation in the 30 days prior to discharge (or since admission if less than 30 days). States should track client-level data by matching admission to discharge records through a unique Statewide client ID.
DATA SOURCE(S)	Primary data collection based on State standard for admission and discharge client data (e.g., State-based information system, SAIS, etc.).
DATA ISSUES	State instruments may differ from proposed definitions. States may lack a unique statewide client ID to link admission and discharge records.
FORM	T6

State Description of Social Support of Recovery Data Collection (Form T6)

STATE CONFORMANCE TO INTERIM STANDARD	States should detail exactly how this information is collected. Where data and methods vary from interim standard, variance should be described.
DATA SOURCE	What is the source of data for table T6 (select all that apply): □ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ Administrative data source □ Other Specify ___________________
EPISODE OF CARE	How is the admission/discharge basis defined for table T6 (Select one) □ Admission is on the first date of service, prior to which no service has been received for 30 days AND discharge is on the last date of service, subsequent to which no service has been received for 30 days □ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the last date of service in a Program/Service Delivery Unit □ Other Specify ___________________________________________
DISCHARGE DATA COLLECTION	How was discharge data collected for table T6 (select all that apply) □ Not applicable, data reported on form is collected at time period other than discharge→ Specify: □ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ admission □ discharge □ other ______ □ Discharge data is collected for the census of all (or almost all) clients who were admitted to treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost all) clients who were admitted to treatment □ Discharge records are not collected for approximately ___ % of clients who were admitted for treatment
RECORD LINKING	Was the admission and discharge data linked for table T6 (select all that apply): □ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier (UCID) Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID □ No, State Management Information System does not utilize UCID that allows comparison of admission and discharge data on a client specific basis (data developed on a cohorts basis) or State relied on other data sources for post admission data □ No, admission and discharge records were matched using probabilistic record matching.
IF DATA IS UNAVAILABLE	If data is not reported, why is State unable to report (select all that apply): □ Information is not collected at admission □ Information is not collected at discharge □ Information is not collected by the categories requested □ State collects information on the indicator area but utilizes a different measure.
DATA PLANS IF DATA IS NOT AVAILABLE	State must provide time-framed plans for capturing self-help participation status data on all clients, if data is not currently available. Plans should also discuss barriers, resource needs and estimates of cost.

FORM T7: RETENTION

Length of Stay (in Days) of Clients Completing Treatment

Most recent year for which data are available: _____________

STATE:

Length of Stay
level of care	average (Mean)	median (Median)	Interquartile range
DETOXIFICATION (24-HOUR CARE)
1. Hospital Inpatient
2. Free-Standing Residential
REHABILITATION/ RESIDENTIAL
3. Hospital Inpatient
4. Short-term (up to 30 days)
5. Long-term (over 30 days)
AMBULATORY (OUTPATIENT)
6. Outpatient
7. Intensive Outpatient
8. Detoxification
9. Opioid Replacement therapy

How to complete Form T7 – Retention

Length of stay (LOS) is described by the date of first individual or group addiction counseling service to the date of last contact for each level of care (date at which no additional services are received within thirty days).

Use the column labeled Average to report the average (mean) length of stay.

Use the column labeled Median to report the median length of stay.

Use the column labeled Interquartile Range to report the 25^th and 75^th percentile values for the length of stay.

Refer to the Levels of Care as defined in the instructions for Form 10a.

SECTION IVb

PREVENTION PERFORMANCE MEASURES

Data requested in the following tables:

Form P1 – NOMs Domain: Reduced Morbidity

Measure: 30-Day Use

Form P2 – NOMs Domain: Reduced Morbidity

Measure: Perception of Risk/Harm of Use

Form P3 – NOMs Domain: Reduced Morbidity

Measure: Age of First Use

Form P4 – NOMs Domain: Reduced Morbidity

Measure: Perception of Disapproval/Attitudes

Form P5 – NOMs Domain: Employment/Education

Measure: Perception of Workplace Policy

Form P6 – NOMs Domain: Employment/Education

Measure: ATOD-Related Suspensions and Expulsions; In development

Form P7 – NOMs Domain: Employment/Education

Measure: Average Daily School Attendance Rate

Form P8 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol-Related Traffic Fatalities

Form P9 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol- and Drug-Related Arrests

Form P10 – NOMs Domain: Social Connectedness

Measure: Family Communications Around Drug and Alcohol Use

Form P11 – NOMs Domain : Retention

Measure: Youth Seeing, Reading, Watching, or Listening to a Prevention Message

Form P12a and P12b – Number of Persons Served by Age, Gender, Race, and Ethnicity

NOMs Domain: Access/Capacity

Measure: Persons Served by Age, Race, and Ethnicity

Form P13 (Optional) – Number of Persons Served by Type of Intervention

NOMs Domain: Access/Capacity

Measure: Persons Served by Type of Intervention

Form P14 – Evidence-Based Programs and Strategies by Type of Intervention

NOMs Domain: Retention

NOMs Domain: Use of Evidence-Based Programs

Measure: Evidence-Based Programs and Strategies

Form P15 – Total Number of Evidence-Based Programs/ Strategies (EBP)

NOMs Domain: Cost Effectiveness

Measure: Total SAPT Block Grant dollars spent on Evidence-Based Programs and Strategies.

Introduction

The National Outcome Measures (NOMs) are a set of domains and measures that the Substance Abuse and Mental Health Services Administration (SAMHSA) will use to accomplish its vision and to meet all of its Federal reporting requirements, thus reducing burden and redundancy for grantees.

SAMHSA’s vision is a “Life in the Community for Everyone: Building Resilience and Facilitating Recovery.” Within this vision are three goals: accountability, capacity, and effectiveness for all Agency initiatives. The NOMs are SAMHSA’s means to address its accountability goal and performance-monitoring approach. Given the differing components of SAMHSA, the actual measures are slightly different across its three Centers—Center for Mental Health Services, Center for Substance Abuse Prevention (CSAP), and Center for Substance Abuse Treatment. The actual measures for each Center are posted on the SAMHSA Web site (http://www.nationaloutcomemeasures.samhsa.gov).

The NOMs Data Collection and Reporting Forms are to be completed as part of the State’s annual Substance Abuse Prevention and Treatment (SAPT) Block Grant application.

For the Federal fiscal year 2011 SAPT Block Grant application, States must report their NOMs data for the compliance year based on Federal fiscal year 2008―October 1, 2007, through September 30, 2008.

For purposes of this section, unless otherwise noted, the term “State” refers to States, Territories, and Native American tribes that receive SAPT Block Grant funding.

.

Forms P1 through P11 – Information

A. Pre-populated Data

CSAP and the States have agreed that the State-level reporting requirement for the NOMs listed in Forms P1–P11 will be fulfilled through the use of extant data from sources including the National Survey on Drug Use and Health (NSDUH), the Fatality Analysis Reporting System (FARS) of the National Highway Traffic Safety Administration, the Uniform Crime Report (UCR) of the Federal Bureau of Investigation, and the National Center for Education Statistics (NCES) of the U.S. Department of Education. These pre-populated State-level NOMs will meet most of the State-level NOMs reporting requirements for the prevention portion of the SAPT Block Grant funding. These data will be pre-populated into the data tables by CSAP.

NOMs Domain - Reduced Morbidity—Abstinence from Drug Use/Alcohol Use

Form P1: 30-Day Use

Form P2: Perception of Risk/Harm of Use

Form P3: Age of First Use

Form P4: Perception of Disapproval/Attitudes

NOMs Domain - Employment/Education

Form P5: Perception of Workplace Policy

Form P6: ATOD-Related Suspensions and Expulsions; In development

Form P7: Average Daily School Attendance Rate

NOMs Domain - Crime and Criminal Justice

Form P8: Alcohol-Related Traffic Fatalities

Form P9: Alcohol- and Drug-Related Arrests

NOMs Domain - Social Connectedness

Form P10: Family Communications Around Drug and Alcohol Use

NOMs Domain - Retention

Form P11: Youth Seeing, Reading, Watching, or Listening to a Prevention Message

In this Block Grant application, pre-populated data are automatically provided to fulfill the majority of the reporting requirements. States may submit requests for approval to use substitute data.

Territories and Native American tribes for which there are no NSDUH, FARS, UCR, and/or NCES data will not be required to report on those measures at the State level, but will be encouraged to provide substitute data.

B. Application To Substitute Data

If a State wishes to substitute State-generated data for SAMHSA-provided national data, the State must request approval for the substitution through its CSAP State Project Officer (SPO).

The application for substitution must demonstrate at a minimum that:

• Data are at the State level.

• Data are collected, analyzed, and reported on an annual basis.

• Data are collected through a valid sample or true census (i.e., a convenience sample is not acceptable).

• Data protocol for data collection timeline, sample methodology, source (sample or census instrument), collection schedule, analysis, and reporting each meet reasonable standards of quality.

• Data will have to have been collected for 1 year before the date of the requested substitution in order to assess acceptability for substitution.

• Data shall be provided to SAMHSA/CSAP on an annual basis.

It should be noted that if a State agrees to use SAMHSA data this year as sources for the NOMs, this does not preclude the State in future years from requesting a substitution.

To substitute the pre-populated data with State-generated data, States must complete the following steps:

Complete an Application Form to Substitute Data (Prevention Attachment A). The form must be submitted to the SPO by July 20, 2010, who will submit it to SAMHSA/CSAP for review. CSAP will review the survey and the information provided, consider the validity issues compared to NSDUH, and provide a decision to the State by August 3, 2010.

1. If SAMHSA denies the substitution application, the State may appeal the decision. To appeal, the State will be asked to provide the following information using the Substitution Appeal Form (Prevention Attachment B):

   1. The specific measure that is being appealed

   2. The rationale for appealing SAMHSA’s decision

   3. A copy of the original substitution application

   4. Additional data/analysis to address concerns identified by SAMHSA

After receiving a denial, a State will have until August 17, 2010 to submit an appeal. SAMHSA will then provide an appeal decision to the State by August 31, 2010

2. After receiving the approval from SAMHSA, the State will include the substitute data in the Block Grant application. This entails two steps:

   1. Enter the substitute data in the appropriate Form Approved Substitute Data for the appropriate NOM.

   2. Complete the Approved Substitute Data Submission Form (Prevention Attachment C).

The deadline for full application submission to SAMHSA is October 1, 2010.

C. Supplemental Data

States may also wish to provide additional data related to the NOMs. An approved substitution is not required to provide this supplemental data. The data can be included in the Block Grant appendix. When describing the supplemental data, States should provide any relevant Web addresses (URLs) that provide links to specific State data sources.

Check here if you have submitted supplemental data or supporting documents in the BGAS appendix.

Provide a brief summary of the supplemental data included in the appendix:

D. Instructions for Completing Forms

Column A: Measure - The SAMSHA-defined measure for the domain listed.

Column B: Question/Response

• Source Survey Item: For Forms P1P5, P10, and P11, the source is the NSDUH. For Forms P7P9, other “archival” sources are identified. The specific language used for each item is provided. Note: Form P6 is not included in this Application Guidance.

• Response Option: The range of responses that are provided for the survey item.

• Outcome Reported: The specific responses that are included in the calculation provided for the item.

Age: The age range for which the responses are provided. The Federal fiscal year (FY) 2011 application identifies FY 2008 as the baseline year for the NOMs data.

Column C: Pre-populated Data - Pre-populated data are provided; see description below.

Column D: Approved Substitute Data - States with pre-approval to submit substitute data will be able to enter the data for the item in this column. Note: If this column is left blank, the pre-populated data will be used.

Form P1 – NOMs Domain: Reduced Morbidity - Abstinence from Drug Use/Alcohol Use

Measure: 30-Day Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. 30-day Alcohol Use	Source Survey Item: NSDUH Questionnaire. “Think specifically about the past 30 days, that is, from [DATEFILL] through today. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used alcohol during the past 30 days.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
2. 30-day Cigarette Use	Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that is, since [DATEFILL], on how many days did you smoke part or all of a cigarette?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having smoked a cigarette during the past 30 days.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
3. 30-day Use of Other Tobacco Products	Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that is, since [DATEFILL], on how many days did you use [other tobacco products]†?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used a tobacco product other than cigarettes during the past 30 days, calculated by combining responses to questions about individual tobacco products (snuff, chewing tobacco, pipe tobacco).
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
4. 30-day Use of Marijuana	Source Survey Item: NSDUH Questionnaire: “Think specifically about the past 30 days, from [DATEFILL] up to and including today. During the past 30 days, on how many days did you use marijuana or hashish?” [Response option: Write in a number between 0 and 30.] Outcome Reported: Percent who reported having used marijuana or hashish during the past 30 days.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
5. 30-day Use of Illegal Drugs Other Than Marijuana	Source Survey Item: NSDUH Questionnaire: “Think specifically about the past 30 days, from [DATEFILL] up to and including today. During the past 30 days, on how many days did you use [any other illegal drug]‡?” Outcome Reported: Percent who reported having used illegal drugs other than marijuana or hashish during the past 30 days, calculated by combining responses to questions about individual drugs (heroin, cocaine, stimulants, hallucinogens, inhalants, prescription drugs used without doctors’ orders).
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008

^† NSDUH asks separate questions for each tobacco product. The number provided combines responses to all questions about tobacco products other than cigarettes.

^‡ NSDUH asks separate questions for each illegal drug. The number provided combines responses to all questions about illegal drugs other than marijuana or hashish.

Form P2 – NOMs Domain: Reduced Morbidity - Abstinence from Drug Use/Alcohol Use

Measure: Perception of Risk/Harm of Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Perception of Risk From Alcohol	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
2. Perception of Risk From Cigarettes	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they smoke one or more packs of cigarettes per day?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
3. Perception of Risk From Marijuana	Source Survey Item: NSDUH Questionnaire: “How much do people risk harming themselves physically and in other ways when they smoke marijuana once or twice a week?” [Response options: No risk, slight risk, moderate risk, great risk] Outcome Reported: Percent reporting moderate or great risk.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008

Form P3 – NOMs Domain: Reduced Morbidity - Abstinence from Drug Use/Alcohol Use

Measure: Age of First Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Age at First Use of Alcohol	Source Survey Item: NSDUH Questionnaire: “Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink.” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of alcohol.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
2. Age at First Use of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you smoked part or all of a cigarette?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of cigarettes.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
3. Age at First Use of Tobacco Products Other Than Cigarettes	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used [any other tobacco product]†?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of tobacco products other than cigarettes.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
4. Age at First Use of Marijuana or Hashish	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used marijuana or hashish?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of marijuana or hashish.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008
5. Age at First Use of Illegal Drugs Other Than Marijuana or Hashish	Source Survey Item: NSDUH Questionnaire: “How old were you the first time you used [other illegal drugs]‡?” [Response option: Write in age at first use.] Outcome Reported: Average age at first use of other illegal drugs.
	Ages 12–17 - FFY 2008
	Ages 18+ - FFY 2008

^† The question was asked about each tobacco product separately, and the youngest age at first use was taken as the measure.

^‡ The question was asked about each drug in this category separately, and the youngest age at first use was taken as the measure.

Form P4 – NOMs Domain: Reduced Morbidity - Abstinence from Drug Use/Alcohol Use

Measure: Perception of Disapproval/Attitudes

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Disapproval of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age smoking one or more packs of cigarettes a day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2008
2. Perception of Peer Disapproval of Cigarettes	Source Survey Item: NSDUH Questionnaire: “How do you think your close friends would feel about you smoking one or more packs of cigarettes a day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent reporting that their friends would somewhat or strongly disapprove.
	Ages 12–17 - FFY 2008
3. Disapproval of Using Marijuana Experimentally	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age trying marijuana or hashish once or twice?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2008
4. Disapproval of Using Marijuana Regularly	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age using marijuana once a month or more?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2008
5. Disapproval of Alcohol	Source Survey Item: NSDUH Questionnaire: “How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?” [Response options: Neither approve nor disapprove, somewhat disapprove, strongly disapprove] Outcome Reported: Percent somewhat or strongly disapproving.
	Ages 12–17 - FFY 2008

Form P5 – NOMs Domain: Employment/Education

Measure: Perception of Workplace Policy

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
Perception of Workplace Policy	Source Survey Item: NSDUH Questionnaire: “Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you?” [Response options: More likely, less likely, would make no difference] Outcome Reported: Percent reporting that they would be more likely to work for an employer conducting random drug and alcohol tests.
	Ages 15–17 - FFY 2008
	Ages 18+ - FFY 2008

Form P6 – NOMs Domain: Employment/Education

Measure: ATOD-Related Suspensions and Expulsions

In development.

Form P7 – NOMs Domain: Employment/Education

Measure: Average Daily School Attendance Rate

A. Measure	B. Source	C. Pre-populated Data	D. Approved Substitute Data
Average Daily School Attendance Rate	Source: National Center for Education Statistics, Common Core of Data: The National Public Education Finance Survey available for download at http://nces.ed.gov/ccd/stfis.asp Measure calculation: Average daily attendance (NCES defined) divided by total enrollment and multiplied by 100.
	FFY 2008

Form P8 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol-Related Traffic Fatalities

A. Measure	B. Source	C. Pre-populated Data	D. Approved Substitute Data
Alcohol-Related Traffic Fatalities	Source: National Highway Traffic Safety Administration Fatality Analysis Reporting System Measure calculation: The number of alcohol-related traffic fatalities divided by the total number of traffic fatalities and multiplied by 100.
	FFY 2008

Form P9 – NOMs Domain: Crime and Criminal Justice

Measure: Alcohol- and Drug-Related Arrests

A. Measure	B. Source	C. Pre-populated Data	D. Approved Substitute Data
Alcohol- and Drug-Related Arrests	Source: Federal Bureau of Investigation Uniform Crime Reports Measure calculation: The number of alcohol- and drug-related arrests divided by the total number of arrests and multiplied by 100.
	2008

Form P10 – NOMs Domain: Social Connectedness

Measure: Family Communications Around Drug and Alcohol Use

A. Measure	B. Question/Response	C. Pre-populated Data	D. Approved Substitute Data
1. Family Communications Around Drug and Alcohol Use (Youth)	Source Survey Item: NSDUH Questionnaire: “Now think about the past 12 months, that is, from [DATEFILL] through today. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? By parents, we mean either your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.” [Response options: Yes, No] Outcome Reported: Percent reporting having talked with a parent.
	Ages 12–17 - FFY 2008
2. Family Communications Around Drug and Alcohol Use (Parents of children aged 12–17)	Source Survey Item: NSDUH Questionnaire: “During the past 12 months, how many times have you talked with your child about the dangers or problems associated with the use of tobacco, alcohol, or other drugs?”† [Response options: 0 times, 1 to 2 times, a few times, many times] Outcome Reported: Percent of parents reporting that they have talked to their child.
	Ages 18+ - FFY 2008

^† NSDUH does not ask this question of all sampled parents. It is a validation question posed to parents of 12- to 17-year-old survey respondents. Therefore, the responses are not representative of the population of parents in a State. The sample sizes are often too small for valid reporting.

Form P11 – NOMs Domain: Retention

Measure: Percentage of Youth Seeing, Reading, Watching, or Listening to a Prevention Message

Measure	Question/Response	Pre-populated Data	Approved Substitute Data
Exposure to Prevention Messages	Source Survey Item: NSDUH Questionnaire: “During the past 12 months, do you recall [hearing, reading, or watching an advertisement about the prevention of substance use]†?” Outcome Reported: Percent reporting having been exposed to prevention message.
	Ages 12–17 - FFY 2008

^† This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within a specific context

P-Forms 12a- P-15 – Reporting Period

Reporting Period - Start and End Dates for Information Reported on Forms P12A, P12B, P13, P14 and P15

Instructions for completing reporting Start and End Dates

The following chart is for collecting information on the reporting periods for the data entered in Forms P12A, P12B, P13, P14 and P15.

See: The instructions for and the data entered in Forms P12A, P12B, P13, P14 and P15.

Rows 1 through 5 each correspond to a single form in the current year’s application among the following five forms: P12a, P12b, P13, P14 and P15.

Column A – Enter the reporting period start date.

Column B – Enter the reporting period end date.

The date format to be entered in columns A and B should be month/day/year, as follows.

• Month: enter 2 digits (e.g. January = 01; December = 12)

• Day: enter 2 digits (e.g. 1^st of the month = 01; 15^th of the month =15)

• Year: enter all 4 digits (e.g. 2008, 2009)

Reporting Period Start and End Dates for Information Reported on Forms P12A, P12B, P13, P14 and P15

Please indicate the reporting period (start date and end date) for each of the following forms:

Forms	A. Reporting Period Start Date	B. Reporting Period End Date
Form P12a Individual-Based Programs and Strategies – Number of Persons Served by Age, Gender, Race, and Ethnicity	mm/dd/yyyy	mm/dd/yyyy
Form P12b Population-Based Programs and Strategies – Number of Persons Served by Age, Gender, Race, and Ethnicity	mm/dd/yyyy	mm/dd/yyyy
Form P13 (Optional) Number of Persons Served by Type of Intervention	mm/dd/yyyy	mm/dd/yyyy
Form P14 Number of Evidence-Based Programs and Strategies by Type of Intervention	mm/dd/yyyy	mm/dd/yyyy
Form P15 Total Number of Evidence-Based Programs and Total SAPT BG Dollars Spent on Evidence-Based Programs/Strategies	mm/dd/yyyy	mm/dd/yyyy

Forms P12a and P12b – Number of Persons Served by Age, Gender, Race, and Ethnicity

NOMs Domain: Access/Capacity

Measure: Number of Persons Served by Age, Gender, Race, and Ethnicity

The number of persons served by individual-based programs and strategies is reported in Table P12a and by population-based programs and strategies in Table P12b.

See Form P13 for definitions of activities, practices, procedures, processes, programs, and strategies.

Form P12a: Individual-Based Programs and Strategies—Number of Persons Served by Age, Gender, Race, and Ethnicity

Individual-based programs and strategies include practices and strategies with identifiable goals designed to change behavioral outcomes among a definable population or within a definable geographic area. These programs and strategies are provided to individuals or group of individuals who do not require treatment for substance abuse who receive the services over a period of time in a planned sequence of activities that are intended to inform, educate, develop skills, alter risk behaviors, or deliver services (e.g., a parent education group that meets once a week for 6 weeks).

• A key factor in recording the individual-based programs and strategies is whether or not individual-level information is recorded for the participants (e.g., gender, race/ethnicity, age). In most cases, participants in individual-based programs will complete pre- and post-test questionnaires.

• The individual-based program and strategy data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program or strategy will be recorded multiple times. For example, a young person may receive a prevention curriculum in his/her health class and also participate in an after-school tutoring program. This individual would be reported twice. Individual counts should be unduplicated within a program, but can be duplicated between programs.

• Data reported for individual-based programs should be based on actual counts - not on estimates of people served. MDS users: Individual-based programs that record participant numbers as “exact counts” would be reported in Table P12a.

• Examples of individual-based strategies include:

• School- and community-based curricula

• School- and community-based groups and organizations (e.g., SADD, 4-H, Peer Helpers)

• Alternative activities (e.g., after-school programs)

• Community service activities

• Parent education classes and workshops

Instructions for completing Form P12a

Enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span calendar years, include the data for the reporting year only.

Category A. Age

Enter total number of participants for each age group listed.

If age is not known, enter the total in the Age Not Known subcategory.

Category B. Gender

Enter total number of male and female participants in the applicable rows.

If gender is not known, enter the total in the Gender Not Known subcategory.

Category C. Race

Using the Office of Management and Budget (OMB) designations as a guide, the following racial categories are to be reported:

• White

• Black or African American

• Native Hawaiian/Other Pacific Islander

• Asian

• American Indian/Alaskan Native

Enter total number of participants for each race listed in the applicable rows.

Participants who are more than one race should be added to the totals for each applicable race or to the total for the More Than One Race subcategory. They should not be included in the totals for both. Indicate in question 2 which way the State is reporting.

If race is not known or is other than those listed, enter the total in the Race Not Known or Other subcategory.

Category D. Ethnicity

Enter total number of Hispanic and Not Hispanic participants in the applicable rows.

Question 1: Describe the data collection system you used to collect the NOMs data (e.g., MDS, DbB, KIT Solutions, manual process).

Question 2: Describe how your State’s data collection and reporting processes record a participant’s race, specifically for participants who are more than one race.

Indicate whether the State added those participants to the number for each applicable racial category or whether the State added all those participants to the More Than One Race subcategory.

Form P12a – Individual-Based Programs and Strategies—Number of
Persons Served by Age, Gender, Race, and Ethnicity

Category	Total
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino

Form P12b: Population-Based Programs and Strategies—Number of Persons Served by Age, Gender, Race, and Ethnicity

Population-based programs and strategies include planned and deliberate goal-oriented practices, procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps subject to monitoring and modification. Included within this definition are environmental strategies (which establish or change written and unwritten community standards, codes, laws, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population), one-time or single events (such as a health fair, a school assembly, or the distribution of material), and other activities intended to impact a broad population. The goal is to record the numbers of people impacted by the program or strategy.

• Data reported for population-based programs and strategies should be based on actual numbers (if known) or estimates of people served. For programs and strategies that reach an identifiable population (e.g., an entire county, city, or State, or a targeted age range), it is permissible to use U.S. Census Bureau data (if available) to estimate the number of persons served.

• The population-based program data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program will be recorded multiple times. For example, a young person may attend a high school presentation on substance abuse one day and attend a health fair the next. This individual would be reported twice.

• MDS users: Participants recorded as “estimated counts” could be recorded as population-based programs and strategies.

• Examples of how to record population-based programs and strategies include:

• Brochure dissemination - number of people receiving the brochure

• Radio/TV talk show expert - number of people listening to or viewing the show

• Health fair - number of people attending the fair

• School assembly - number of people attending the assembly

• Public service announcement (PSA) - number of people listening to or viewing the PSA

• Coalition building - number of people in the coalition

• Developing community policies (e.g., restrictions on advertising)―number of people in the community

• Planning, managing, and coordinating efforts to effect positive community change - number of people involved in the planning effort

• Media campaign - number of people living in the “community” impacted by the media campaign

• Other environmental strategies, including media advocacy, keg registration, ID card enforcement, warning labels, server trainings - number of people impacted by the strategy

Instructions for completing Form P12b

Enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include numbers from the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span calendar years, include the data for the reporting year only.

Category A. Age

Enter total number served for each age group listed.

If age is not known, enter the total in the Age Not Known subcategory.

Category B. Gender

Enter total number of males and females served in the applicable rows.

If gender is not known, enter the total in the Gender Not Known subcategory.

Category C. Race

Using the Office of Management and Budget (OMB) designations as a guide, the following racial categories are to be reported:

• White

• Black or African American

• Native Hawaiian/Other Pacific Islander

• Asian

• American Indian/Alaskan Native

Enter total number served for each race listed in the applicable rows. Enter number of persons served identified as more than one race in the applicable row. Do not enter numbers for those persons in each applicable racial subcategory.

If race is not known or is other than those listed, enter the total in the Race Not Known or Other subcategory.

Category D. Ethnicity

Enter total number of Hispanic and Not Hispanic participants in the applicable rows.

Table P12b – Population-Based Programs and Strategies—Number of
Persons Served by Age, Gender, Race, and Ethnicity

Category	Total
A. Age
0–4
5–11
12–14
15–17
18–20
21–24
25–44
45–64
65 and Over
Age Not Known
B. Gender
Male
Female
Gender Not Known
C. Race
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
D. Ethnicity
Hispanic or Latino
Not Hispanic or Latino

Optional Form P13 – Number of Persons Served by Type of Intervention

NOMs Domain: Access/Capacity

Measure: Number of Persons Served by Type of Intervention

Interventions include activities, practices, procedures, processes, programs, services, and strategies (as defined below):

Activity

• A specified pursuit in which an organization or person partakes to remedy a specific problem or issue; includes level of intensity and frequency (e.g., parent training classes on underage drinking prevention strategies).

• A process or procedure intended to stimulate learning through actual experience.

Practices

Repeated performance of an activity or strategy to perfect a skill or an outcome (e.g., Best practices - Strategies, activities, approaches, or programs shown through research and evaluation to be effective at preventing and/or delaying substance use and abuse; Exemplary Practices - Those which long-term empirical research and evaluation have documented to be effective in reducing substance use and abuse; Promising Practices - Strategies, activities, approaches, or programs for which the level of certainty from available evidence is too low to support generalized conclusions, but for which there is some empirical basis for predicting that further research could support such conclusions).

Procedures

A series of steps taken to accomplish an end.

Processes

A series of actions, changes, or functions bringing about a results, i.e., strengthening or enhancing individual (community, family, etc.) knowledge and skills that are essential in healthy behaviors.

Programs

A system or coordinated set of activities, approaches, strategies, services, opportunities, practices or projects, designed to influence changes in behaviors, knowledge, attitudes, organizational practices and policies that are designed to achieve specific objectives over time (e.g., creating healthy people and healthy environments).

Services

Performance of work or duties or provision of space and equipment helpful to achieve health or wellness.

Strategy A plan of action (activities – e.g., policy changes, practices, or approaches), that can be implemented to achieve specific objectives and for which a strong evidence base may or may not exist.

Intervention types are defined as:

• Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Row 1— Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, after-school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Universal Indirect. Row 2— Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Selective. Row 3―Activities targeted to individuals or a subgroup of a population whose risk of developing a disorder is significantly higher than average.

• Indicated. Row 4― Activities targeted to individuals, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Totals. Row 5—Insert the totals for each column.

Instructions for completing Form P13 (Optional)

For each of the intervention types defined above, enter the number of persons who were served by programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or that span the calendar year, include the data for each year in which the program or strategy is funded. When a program involves multiple strategies (e.g., Project Northland) report as one program in either the individual-based programs and strategies or in the population-based programs and strategies.

Column A: Individual-Based Programs and Strategies - Include practices and strategies with identifiable goals designed to change behavioral outcomes among a definable population or within a definable geographic area. Individual-based programs and strategies are provided to individuals or group of individuals who receive the services over a period of time in a planned sequence of activities that are intended to inform, educate, develop skills, alter risk behaviors, or provide direct services (e.g., a parent education group that meets once a week for 6 weeks).

• A key factor in recording the individual-based programs and strategies is whether or not individual-level information is recorded for the participants (e.g., gender, race/ethnicity, age). In most cases, participants in individual-based programs will complete pre- and post-test questionnaires.

• The individual-based program and strategy data may be provided as a duplicate count; that is, an individual who participates in more than one individual-based program or strategy will be recorded multiple times. For example, a young person may receive a prevention curriculum in his/her health class and also participate in an afterschool tutoring program. This individual would be reported twice. Individual counts should be unduplicated within a program, but can be duplicated between programs.

• Data reported for individual-based programs should be based on actual counts―not on estimates of people served. MDS users: Participants recorded as “exact counts” could be recorded as individual-based programs and strategies.

• Examples of individual-based strategies include the following:

• School- and community-based curricula

• School- and community-based groups and organizations (e.g., SADD, 4-H, Peer Helpers)

• Alternative activities (e.g., afterschool programs, drop-in centers)

• Community service activities

• Parent education classes and workshops

• Participants in server training classes

Column B: Population-Based Programs and Strategies―Include planned and deliberate goal- oriented practices, procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps subject to monitoring and modification. Included within this definition are environmental strategies (which establish or change written and unwritten community standards, codes, laws, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population.), one-time or single events (such as a health fair, a school assembly, or the distribution of material), and other activities intended to impact a broad population. The goal is to record the numbers of people impacted by the program or strategy.

• Data reported for population-based programs and strategies should be based on actual numbers (if known) or estimates of people served. For programs and strategies that reach an identifiable population (e.g., an entire county, city, or State), it is permissible to use U.S. Census Bureau data (if available) to estimate the number of persons served.

• The population-based program data may be provided as a duplicate count; that is, an individual who participates in more than one population-based program will be recorded multiple times. For example, a young person may attend a high school presentation on substance abuse one day and attend a health fair the next. This individual would be reported twice. When a strategy is used with the same population (e.g., weekly radio shows) the goal would be to provide annual unduplicated counts within that strategy.

• MDS users: Participants recorded as “estimated counts” could be recorded as population-based programs and strategies.

• Examples of how to record population-based programs and strategies include:

• Brochure dissemination―number of people receiving the brochure

• Radio/TV talk show expert―number of people listening to or viewing the show

• Health fair―number of people attending the fair

• School assembly―number of people attending the assembly

• PSAs―number of people listening to or viewing the PSA

• Coalition building―number of people in the coalition

• Developing community policies (e.g., restrictions on advertising)―number of people in the community

• Planning, managing, and coordinating efforts to effect positive community change―number of people involved in the planning effort

• Media campaign―number of people living in the “community” impacted by the media campaign

• Other environmental strategies, including media advocacy, keg registration, ID card enforcement, warning labels, server trainings (number of people impacted by the strategy)

Form P13 (Optional) – Number of Persons Served by Type of Intervention

Intervention Type	Number of Persons Served by Individual- or Population-Based Program or Strategy
	A. Individual-Based Programs and Strategies	B. Population-Based Programs and Strategies
1. Universal Direct		N/A
2. Universal Indirect	N/A
3. Selective		N/A
4. Indicated		N/A
5. Total

Form P14 – Evidence-Based Programs and Strategies by Type of Intervention

NOMs Domain: Retention

NOMs Domain: Evidence-Based Programs and Strategies

Measure: Number of Evidence-Based Programs and Strategies

Definition of Evidence-Based Programs and Strategies: The guidance document for the Strategic Prevention Framework State Incentive Grant, Identifying and Selection Evidence-based Interventions, provides the following definition for evidence-based programs:

● Inclusion in a Federal List or Registry of evidence-based interventions

● Being Reported (with positive effects) in a peer-reviewed journal

● Documentation of effectiveness based on the following guidelines:

- Guideline 1: The intervention is based on a theory of change that is documented in a clear logic or conceptual model; and

• Guideline 2: The intervention is similar in content and structure to interventions that appear in registries and/or the peer-reviewed literature; and

• Guideline 3: The intervention is supported by documentation that it has been effectively implemented in the past, and multiple times, in a manner attentive to Identifying and Selecting Evidence-Based Interventions scientific standards of evidence and with results that show a consistent pattern of credible and positive effects; and

• Guideline 4: The intervention is reviewed and deemed appropriate by a panel of informed prevention experts that includes: well-qualified prevention researchers who are experienced in evaluating prevention interventions similar to those under review; local prevention practitioners; and key community leaders as appropriate, e.g., officials from law enforcement and education sectors or elders within indigenous cultures.

1. Describe the process the State will use to implement the guidelines included in the above definition.

2. Describe how the State collected data on the number of programs and strategies. What is the source of the data?

Instructions for completing Form P14

Enter the number of evidence-based programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding. For programs and strategies lasting longer than a year or which span the fiscal year, include the data for the reporting year only.

Intervention types are defined as:

• Universal. Activities targeted to the general public or a whole population group that has not been identified on the basis of individual risk.

• Universal Direct. Column A - Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, after-school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

• Universal Indirect. Column B - Interventions support population-based programs and environmental strategies (e.g., establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

• Column C - Insert the total for each row of the number in columns A and B. Note: If data collected do not differentiate by Universal Direct and Universal Indirect, enter the total number of Universal Programs in column C.

• Selective. Column D - Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

• Indicated. Column E - Activities targeted to individuals, identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

• Totals. Column F - Totals for columns C, D, and E.

For each intervention type listed above, record the following information:

• Row 1: Number of evidence-based programs and strategies. Enter the number of evidence-based programs and strategies:

• Report the number of evidence-based programs and strategies funded by SAPT Block Grant funds. For example, if a State funds 10 providers and each provider implements 3 evidence-based programs and strategies, and each program is implemented 3 times, the State would report “90” as the number of evidence-based programs and strategies.

• Include all evidence-based programs and strategies that were funded wholly or in part by SAPT Block Grant funds during the calendar year. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding.

For programs and strategies lasting longer than a year or that span the calendar year, include the data for the reporting year only.

• Row 2: Total number of programs and strategies. Enter the total number of programs and strategies:

• Report the number of all programs and strategies funded by SAPT Block Grant funds. For example, if a State funds 10 providers and each provider implement 5 programs and strategies, and each program is implemented 3 times, the State would report “150”as the number of programs and strategies.

• Report the number of all programs and strategies funded wholly or in part by SAPT Block Grant funds during the calendar year. Include evidence-based programs and strategies in the total. Include the program and strategy even if the SAPT Block Grant funding constituted a minor part of the funding.

For programs and strategies lasting longer than a year or that span the fiscal year, include the data in each year in which the program or strategy operates. Note: For consistency with Forms P12a and P12b the highlighted sentence should read, For programs and strategies lasting longer than a year or that span calendar years, include the data for the reporting year only.

• Row 3: Percent of evidence-based programs and strategies. Determine this by the following formula:

Percent of evidence-based programs and strategies:

= Number of evidence-based programs and strategies x 100

Total number of programs and strategies

Form P14 – Number of Evidence-Based Programs and Strategies by Type of Intervention

	Number of Programs and Strategies by Type of Intervention
	A. Universal Direct	B. Universal Indirect	C. Universal Total	D. Selective	E. Indicated	F. Total
1. Number of Evidence-Based Programs and Strategies Funded
2. Total number of Programs and Strategies Funded
3. Percent of Evidence-Based Programs and Strategies

Form P15 – FY 2008 Total Number of Evidence Based Programs and Total SAPT BG Dollars Spent on Evidence-Based Programs and Strategies

NOMs Domain: Total Number of Evidence-Based Programs and Strategies

Measure: Total FY 2008 SAPT Block Grant Dollars Spent on Evidence-Based programs and Strategies

See: Attachment D – Table 1 for Optional Worksheet for Form P-15

Instructions for completing Form P-15

FY 2008 Total Number of Evidence-Based Programs and Strategies and the Total FFY 2008 SAPT Block Grant Dollars Spent on Evidence-Based Programs/Strategies.

See: The instructions for Form P-14 for the Definition, Criteria and Guidance for identifying and selecting Evidence-Based Programs and Strategies. Also see definitions for types of interventions in Form P-14 instructions (Universal Direct, Universal Indirect, Selective, and Indicated.

See: Prevention Attachment D for Form P-15 “Optional” Worksheet – FFY 2008 Total Number of Evidence-based Programs and Strategies and the Total FFY 2008 SAPT Block Grant dollars spent on Evidence-Based Programs.

Column 1 – IOM Categories are listed.

Column 2 – Place the Total number of evidence-based programs/strategies for each IOM category (Universal Direct, Universal Indirect, Selective, and Indicated).

Column 3 - Take the total number of evidenced-based programs/strategies for each IOM category and then put the Total FFY 2008 SAPT Block Grant $ dollars Spent on those evidence-based Programs/strategies for each IOM category in column 3. Then, put the total FFY 2008 SAPT Block Grant dollars spent on evidence-based programs/strategies on the bottom line of column 3.

Form P15 – FY 2008 Total Number of Evidence Based Programs and Total SAPT BG Dollars Spent on Evidence-Based Programs/Strategies

FY 2008 Total Number of Evidence-Based Programs/Strategies for IOM Category below:		FY 2008 Total SAPT Block Grant $Dollars Spent on evidence-based Programs/Strategies
Universal Direct	Total #	$
Universal Indirect	Total #	$
Selective	Total #	$
Indicated	Total #	$
	Total EBPs:	Total Dollars Spent: $

Note: See definitions for types of interventions in the instructions for P-14 (Universal Direct, Universal Indirect, Selective, and Indicated)

Prevention Attachment A:

Application Form to Substitute Data

1. Contact Information

State/Territory/tribe:

Name of the applicant (first and last name):

Title:

 Mr.  Ms.  Dr.  Other _____________________

State position:

Organization:

Department:

Mailing address:

E-mail address:

Telephone: Fax:

2. Measure Labels

Label of the National Outcome Measure (NOM) being replaced:

Label of the substituted measure (if not identical to the NOM):

3. Narrative Justification

Provide a brief description of the reasons for the substitution. Continue on the back of the page if necessary.

4. Data Source for Substituted Measure

Name of the agency or organization responsible for data collection:

Name of contact person at data collection agency/organization (first and last name):

E-mail address:

Telephone:

Most recent year for which data are available:

Is data collection repeated every year?

 Yes  No (Indicate frequency of data collection.)______________________

Are trend data available?

 Yes (Indicate start year of trend data.)_________________________  No

What is the mode of data collection?  Census  Survey (Please complete item 5.)

 Other (Please describe.)

5. Survey Description

(Skip if mode of data collection is not a survey.)

The following questions refer to the most recent implementation of the survey.

Date of data collection:

Sample size:

Sampling ratio (sample size divided by the size of the target population):

What type of sampling strategy was used to select respondents? (Please check one.)

• Convenience sample (no statistical sampling techniques were used)

• Probability sample (statistical sampling techniques were used)

The following four questions apply to probability samples only.

If the sample is stratified, please identify each stratum:

If cluster sampling was used, please identify the clustering unit(s):

If a multistage design was used, please identify the unit sampled at each stage:

Potential sources of bias in the sample design:

The following questions apply to all surveys.

Method of administration:  Mail-in  Telephone  Face-to-face

 School-based: self-administered  Self-administered: survey site other than a school

 Other (Please specify.)

Was the interview computer-assisted?  Yes  No

Name of the survey instrument:

What was the survey response rate (i.e., multiply the number who took the survey/original sample size by 100)?

Were there validity and reliability tests of the survey items constituting the substitute measure?

 No

 Yes (Please describe reliability/validity study/studies.)

Are there any published validity/reliability studies for this instrument?

 No

 Yes (Please provide bibliographic information.)

6. Dataset Submission Information

Name of the data file(s) being submitted:

Description of data file(s) (Include format and size.):

For each data file, describe the content of the data records (e.g., “Each record contains all of the information for a single individual.”):

Names of documentation files:

Description of documentation file(s):

Total number of files being submitted:

Instructions for Completing the Substitution Application

Introduction

This form should be completed if a State wishes to substitute data collected through a State effort for the prepopulated National Outcome Measures (NOMs) on the NOMs Data Collection and Reporting Forms. If the grantee is requesting substitutions for more than one NOM, one application should be completed for all NOMs for which a substitution is requested. The following section contains instructions, examples, and clarifications for completing the form.

Instructions for Completing the Form

Item 1

Provide contact information for the person responsible for this application. The person should be able to answer any further questions that may arise about the requested measure substitution and the source of data for the substituted measure.

Item 2

Label of the National Outcome Measure (NOM) being replaced:

Fill in the label of the NOM for which the substitution is requested.

Examples:

“30-Day Use of Marijuana”

“Alcohol-Related Arrests”

Label of the substituted measure:

If the substituted measure has a label that is different from the NOM, fill in the label.

Examples:

“Past Month Use of Marijuana”

“Alcohol-Related Offenses”

If the substituted measure has a label identical to the NOM, leave the space blank.

Item 3

Provide reasons why the proposed substitution will be a better representation of the State’s data on this measure. For example, if the State has an ongoing needs-assessment survey including variables comparable to this NOM, a possible reason for the substitution may be that the sample size of the State survey is larger than the number of respondents from the State selected into the annual National Survey of Drug Use and Health (NSDUH) that is used to pre-populate the form.

Item 4

Name and contact information of the agency or organization responsible for data collection:

For example, if the data source is a needs assessment survey conducted by a local university, provide the name of the university, the academic unit responsible for the survey’s administration, and contact information for the person within that academic unit who is in charge of the survey’s administration. This person should be capable of answering questions about the data collection procedure.

Most recent year for which data are available:

For survey data, enter the date or date range for the most recent survey implementation. For archival data such as school attendance or arrest rates, enter the Federal fiscal year (or school year) for the most recent data available.

Is data collection repeated every year?

Select “Yes” if the data source provides data for every year. If data are not available annually, indicate the frequency with which new data are released (e.g., “every other year on even years”).

Are trend data available?

This question is about the availability of past data. If the data source has been releasing data going back several years, select “Yes” and indicate the date when this source first started releasing data.

What is the mode of data collection?

A census collects data from every individual in the target population. A survey collects data from a selected group of individuals in the target population. A typical example of a data source other than a census or a survey is the records kept by an organization or a State agency such as the State Department of Education or Department of Public Health.

Item 5

This section should be completed only if the data source is a survey.

Date of data collection:

Fill in the date or the range of dates of the most recent survey administration.

Sample size:

Fill in the number of individuals originally selected into the sample, not the number of individuals for whom a completed survey form exists.

Sampling Ratio (Sample size divided by the size of the target population):

For the sample size, use the number originally selected into the sample.

If the sample is stratified, please identify each stratum:

A stratified sample is one where the target population is first divided into groups, and then individuals are selected from each group. This is usually done to ensure that all groups of interest are represented in the sample. For example, the target population could be divided into racial groups and a sample drawn from each group. In this case, the sample would be “stratified by race” and the strata used would be each racial categorization used (e.g., “White, Black, Asian, Other”).

If cluster sampling was used, please identify the clustering unit(s):

Cluster sampling is when a sample is drawn first among clusters of individuals (such as a school or a city block). Once a cluster is selected, either all of the individuals in the cluster are surveyed or a further selection is made among the individuals in the selected clusters.

If a multistage design was used, please identify the unit sampled at each stage:

Multistage sampling usually accompanies clustering. The sampling is done in several stages. First, clusters are selected from a population of all clusters. Then, either individuals or clusters of individuals are selected from the first-stage clusters. For example, several school districts could be selected from the entire pool of districts in the State (first stage). In each selected district, several schools could be selected from the entire pool of schools (second stage). In each sampled school, several students could be selected to take the survey (third stage).

Potential sources of bias in the sample design:

Sources of bias are factors that may affect the representiveness of the sampling design. For example, of households are selected from the phone directory, households without a phone will not be represented in the sample, resulting in biased estimates of variables such as income or type of community. If a large proportion of the sampled individuals refuse to be surveyed, the survey results will over-represent those who are interested in the survey topic.

Method of administration:

A mail-in survey is one where the sampled individuals receive the survey form in the mail, complete the form and mail it back to the administrators. A telephone survey is one where an interviewer interviews the sampled individual on the phone. A face-to-face survey is one where the interviewer contacts and interviews the sampled individual in person. A school-based survey is conducted in schools. Survey forms are handed out to sampled students who complete them (usually in a class period or special assembly) and turn them in. A self-administered survey is one where there is no interviewer. Respondents complete the survey form themselves. Examples of other methods of administration are survey forms sent via e-mail or posted on a Web site.

Was the interview computer-assisted?

A computer-assisted survey is one where the survey form is on a computer instead of a paper form. These can be either self-administered (the respondent sits at the computer and responds to questions appearing on the screen) or conducted through an interviewer who poses the questions to the respondent and enters the responses directly into the computer.

Name of the survey instrument:

Most survey instruments have a title. This can be a special-purpose local survey, for example, “The Any-town County Needs Assessment Survey” or a standardized and widely used instrument such as The Youth Risk Behavior Survey (or YRBSS).

Were there validity and reliability tests of the survey items constituting the substitute measure?

Survey instruments are first tested in pilot studies or cognitive tests to evaluate the clarity of wording, the comprehension level of typical members of the target population, the ability of the questions to provide valid data on the concepts being measured, and the internal consistency of multi-item scales. If such testing was conducted prior to the fielding of the survey, briefly describe the study, including the number of people tested, procedures for selecting test subjects, demographic characteristics of the test subjects, and procedures used to assess reliability and validity.

Are there any published validity/reliability studies for this instrument?

Some validation studies are published in scholarly journals. If the validation study of the survey instrument was published, please provide a standard citation including the title of the article, name of the journal, date of publication, volume and issue numbers, and page numbers.

Item 6

You are required to submit the data and documentation, such as codebooks and variable dictionaries. Please provide file names and format and size information as well as a description of the organization of the data. For example, indicate how the data records are laid out. The most usual layout is to store all of the information from a single individual on a single data record. In a few cases, the record layout may be different; for example, each record containing only some of the information about an individual.

Prevention Attachment B:

Substitution Appeal Form

State/Territory/tribe:

Date substitution application submitted:

Date denial received:

Date appeal submitted:

1. Contact information

Name of the applicant (first and last name):

 Mr.  Ms.  Dr.  Other _____________________

Organization:

Department:

Mailing address:

E-mail address:

Telephone:

Fax:

2. Measure(s) being appealed

National Outcome Measure(s) (NOM) being appealed:

Summarize SAMHSA’s reason(s) for the denial of the substitution:

3. Rationale for the appeal

State the rationale for appealing SAMHSA’s decision:

4. Attach a copy of the original substitution application.

5. Additional data or analysis to support the appeal.

Describe any additional data or analysis that supports the appeal:

Prevention Attachment C:

Approved Substitute Data Submission Form

Create a separate form for each data source.

Grantee and Contact Information

State/Territory/tribe:

Name of contact person (first and last name):

 Mr.  Ms.  Dr.  Other _____________________

Organization:

Department:

Mailing address:

E-mail address:

Telephone: Fax:

Date

Enter the date when the Application Form To Substitute Data was submitted:

If final approval was obtained after an appeal process, enter the date when the appeal was filed:

Enter the date when approval to submit alternative data was obtained:

Measure(s)

Enter the NOMs measure(s) for which State-generated data are being substituted:__________

Prevention Attachment D Table 1

Form P-15 - Optional Worksheet - Total Number of Evidence-Based Programs and Strategies and the Total SAPT Block Grant Dollars Spent on Evidence-Based Programs/Strategies

Instructions for Completing Optional Worksheet - the Total Number of Evidence-Based Programs and Strategies and the Total SAPT Block Grant Dollars Spent on Evidence-based Programs/Strategies

The FFY 2008 Worksheet - Total Number of Evidence-Based Programs and Strategies and the Total SAPT Block Grant Dollars Spent on Evidence-Based programs/Strategies. The optional worksheet is a tool that States may use to record the name and cost of each evidence-based program and strategy.

See: Instructions for Form P-14 for the Definition, Criteria and Guidance for Identifying and Selecting Evidence-Based Programs and Strategies.

1. Table 1: Program/Strategy Detail

A program is defined as a system or coordinated set of activities, approaches, strategies, services, opportunities, practices or projects, designed to influence changes in behaviors, knowledge, attitudes, organizational practices and policies that are designed to achieve specific objectives over time (e.g., creating healthy people and healthy environments).

A strategy is defined as a plan of action (activities – e.g., policy changes, practices, or approaches), that can be implemented to achieve specific objectives and for which a strong evidence base may or may not exist

Universal indirect services are defined as services that support prevention activities, such as population-based activities, and the provision of information and technical assistance. Universal Direct, Selective, and Indicated services are defined as prevention program interventions that directly serve participants.

● Universal. Activities targets sections of the general public or a whole population group that has not been identified on the basis of individual risk.

● Universal Direct – Interventions directly serve an identifiable group of participants but who have not been identified on the basis of individual risk (e.g., school curriculum, afterschool program, parenting class). This could also include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

● Universal Indirect – Interventions support population-based programs and environmental strategies (e.g. establishing ATOD policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies by coalitions.

● Selective. Interventions targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average.

● Indicated. Interventions targeted to individuals identified as having minimal but detectable signs or symptoms foreshadowing disorder or having biological markers indicating predisposition for disorder but not yet meeting diagnostic levels.

Column 1: Program/Strategy Name – In column 1, list by name the evidence-based program and/or strategy that was funded totally or in part with Federal fiscal year (FFY) 2008 Block Grant funds. If there are more than 4 EBPs any each IOM category, name 3 and on the fourth line list the number of the over 3 EBPs you funded. For example: If you name 3 EBPs under Universal Direct and you have 2 more EBPs you funded under Universal Direct, on line 4 you would put 2 more. You do not have to name more than three if you have more than 4 EBPs in that category.

Column 2: Number of Evidence-Based Programs and Strategies. Report the total number for each evidence-based program/strategy listed in column 1, *

Column 3: Subtotal and Total Costs for evidence-Based programs and strategies for each intervention type. Use this column to report the sub-total and total costs for evidence-based programs and strategies. Add the costs for each program or strategy listed in column 1 for each intervention type, and record the subtotal and total in the appropriate rows.

Column 4: Use this column to report Total SAPT Block Grant Funds Spent on Substance Abuse Prevention. Put the total amount on the last row of column 4.

* As well as the cumulative total for Evidence-based programs in the last row of Column 2.

Prevention Attachment D

FFY 2008 (Optional Worksheet for Form P-15)–Total Number of Evidence-based Programs/Strategies and the Total FFY 2008 SAPT Block Grant Dollars Spent on Substance Abuse Prevention Worksheet . Note: Total EBPs and Total dollars spent on EBPs may be transferred to Form P-15.

Note: The Sub-totals for each IOM category and the Total FFY 2008 SAPT Block Grant Dollars spent on Evidence-based programs/strategies may be transferred to Form P-15.

See: The instructions for Form P-14 for the Definition, Criteria and Guidance for identifying and selecting Evidence-Based Programs and Strategies.

Form P15 Table 1: Program/Strategy Detail for Computing the Total Number of Evidence-based Programs and Strategies, and for Reporting Total FFY 2008SAPT Block Grant Funds Spent on Evidence-Based Programs and Strategies.

1	2	3	4
FFY 2008 Program/Strategy Name Universal Direct	FFY 2008 Total Number of Evidence-based Programs and Strategies by Intervention	FFY 2008Total Costs of Evidence based Programs and Strategies for each IOM Category	FFY 2008 Total SAPT Block Grant Funds Spent on Evidence-Based Programs/Strategies
1.
2.
3.
4.
Subtotal
Universal Indirect Programs and Strategies
1.
2.
3.
4.
Subtotal
Selective Programs and Strategies
1.
2.
3.
4.
Subtotal
Indicated Programs and Strategies
1.
2.
3.
4.
Subtotal
Total Number of (EBPs)/Strategies and cost of these EBPs/Strategies	#	$
Total FFY 2008 SAPT Block Grant Dollars $ Spent on Evidence-Based Programs and Strategies			$

Attachment A, Goal 2: Prevention

Answer the following questions about the current year status of policies, procedures, and legislation in your State. Most of the questions are related to Healthy People 2010 (http://www.healthypeople.gov/) objectives. References to these objectives are provided for each applicable question. To respond, check the appropriate box or enter numbers on the blanks provided. After you have completed your answers, copy the attachment and submit it with your application.

1. Does your State conduct sobriety checkpoints on major and minor thoroughfares on a periodic basis? (HP 26-25)

 Yes  No  Unknown

2. Does your State conduct or fund prevention/education activities aimed at preschool children? (HP 26-9)

 Yes  No  Unknown

3. Does your State alcohol and drug agency conduct or fund prevention/education activities in every school district aimed at youth grades K-12? (HP 26-9)

SAPT BLOCK GRANT	OTHER STATE FUNDS	DRUG FREE SCHOOLS
 Yes  No  Unknown	 Yes  No  Unknown	 Yes  No  Unknown

4. Does your State have laws making it illegal to consume alcoholic beverages on the campuses of State colleges and universities? (HP 26-11)

 Yes  No  Unknown

5. Does your State conduct prevention/education activities aimed at college students that include: (HP 26-11c)

Education bureau?  Yes  No  Unknown

Dissemination of materials?  Yes  No  Unknown

Media campaigns?  Yes  No  Unknown

Product pricing strategies?  Yes  No  Unknown

Policy to limit access?  Yes  No  Unknown

6. Does your State now have laws that provide for administrative suspension or revocation of drivers’ licenses for those determined to have been driving under the influence of intoxicants? (HP 26-24)

 Yes  No  Unknown

7. Has the State enacted and enforced new policies in the last year to reduce access to alcoholic beverages by minors such as (HP 26-11c, 12, 23):

Restrictions at recreational and entertainment events at which youth made up a majority of participants/consumers?

 Yes  No  Unknown

New product pricing?

 Yes  No  Unknown

New taxes on alcoholic beverages?

 Yes  No  Unknown

New laws or enforcement of penalties and license revocation for sale of alcoholic beverages to minors?

 Yes  No  Unknown

Parental responsibility laws for a child’s possession and use of alcoholic beverages?

 Yes  No  Unknown

8. Does your State provide training and assistance activities for parents regarding alcohol, tobacco, and other drug use by minors?

 Yes  No  Unknown

9. What is the average age of first use for the following? (HP 26-9 and 27-4), if available

Age 0-5 Age 6-11 Age 12-14 Age 15-18

Cigarettes

Alcohol

Marijuana

10. What is your State’s present legal alcohol concentration tolerance level for: (HP 26-25)?

Motor vehicle drivers age 21 and older?

Motor vehicle drivers under age 21?

11. How many communities in your State have comprehensive, community-wide coalitions for alcohol and other drug abuse prevention (HP 26-23)? ________

12. Has your State enacted statutes to restrict promotion of alcoholic beverages and tobacco that are focused principally on young audiences, (HP 26-11 and 26-16)?

 Yes  No  Unknown

LIST OF FORMS

1 Face Page

2 Table of Contents

3 Funding Agreements/Certifications (PHS 5161)

4 Treatment Needs Assessment Summary Matrix

5 Treatment Needs by Age, Sex, and Race/Ethnicity

6 Intended Use Plan

6a Primary Prevention Planned Expenditure Checklists

6b Primary Prevention Planned Expenditure Checklists

6c Resource Development Checklists

7 State Priorities

8 Substance Abuse State Agency Spending Report

8a Primary Prevention Expenditures Checklists

8b Primary Prevention Expenditurea Checklists

8c Resource Development Expenditures Checklists

9 Substance Abuse Entity Inventory

9a Prevention Strategy Report

10a Treatment Utilization Matrix

10b Number of Persons Served for Alcohol and Other Drug Use in
State-Funded Services By Age, Sex, Race/Ethnicity (Unduplicated Count)

Tables I-IV Maintenance of Effort and Women’s Expenditure Tables

T1 Employment/Education Status

T2 Living Status

T3 Criminal Justice Involvement

T4 Alcohol Use

T5 Other Drug Use

T6 Social Support of Recovery

T7 Retention

P1 NOMs Domain: Reduced Morbidity—Measure: 30-Day Use

P2 NOMs Domain: Reduced Morbidity—Measure: Perception of Risk/Harm of Use

P3 NOMs Domain: Reduced Morbidity—Measure: Age of First Use

P4 NOMs Domain: Reduced Morbidity—Measure: Perception of
Disapproval/Attitudes

P5 NOMs Domain: Employment/Education—Measure: Perception of Workplace
Policy

P6 NOMs Domain: Employment/Education—Measure: ATOD-Related Suspensions
and Expulsions In Development

P7 NOMs Domain: Employment/Education—Measure: Average Daily School
Attendance Rate

P8 NOMs Domain: Crime and Criminal Justice—Measure: Alcohol-Related Traffic
Fatalities

P9 NOMs Domain: Crime and Criminal Justice—Measure: Alcohol- and Drug-
Related Arrests

P10 NOMs Domain: Social Connectedness—Measure: Family Communications
Around Drug and Alcohol Use

P11 NOMs Domain: Retention—Measure: Youth Seeing, Reading, Watching, or
Listening to a Prevention Message

P12a and P12b Number of Persons Served by Age, Gender, Race, and Ethnicity—NOMs
Domain: Access/Capacity—Measure: Persons Served by Age,
Race, and Ethnicity

P13 (Optional) Number of Persons Served by Type of Intervention—NOMs Domain: Access/Capacity - Measure: Persons Served by Type of Intervention

P14 Evidence-Based Programs and Strategies by Type of Intervention—NOMs
Domain: Retention—NOMs Domain: Use of Evidence-Based Programs—
Measure: Evidence-Based Programs and Strategies

P15 Relative Cost of Evidence-Based Program Strategies – (EBPs) NOMs Domain: Cost Effectiveness – Measure: Percentage of Total Prevention Costs Expended on Evidence-Based Programs Strategies

APPENDIX A

STATE PROJECT OFFICERS’ DIRECTORY FOR

CENTER FOR SUBSTANCE ABUSE TREATMENT

CENTER FOR SUBSTANCE ABUSE PREVENTION

As of June 1, 2010

WEB BGAS will contain up-to-date

information on each State’s respective State Project Officer

Page Intentionally Left Blank

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Division of State and Community Assistance Performance Partnership Grant Branch Telephone: (240) 276-2890 Substance Abuse Prevention and Treatment Block Grant Program State Project Officer Directory
State	Project Officers	Telephone	Facsimile	E-Mail
Alabama	Brandon Johnson, Interim	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
Alaska	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	Theresa.Mitchell@samhsa.hhs.gov
Arizona	Melissa Rael	(240) 276-2903	(240) 276-2900	Melissa.Rael@samhsa.hhs.gov
Arkansas	Carol Coley	(240) 276-2892	(240) 276-2900	Carol.Coley@samhsa.hhs.gov
California	Greg Grass	(240) 276-2919	(240) 276-2900	Greg.Grass@samhsa.hhs.gov
Colorado	Melissa Rael	(240) 276-2903	(240) 276-2900	Melissa.Rael@samhsa.hhs.gov
Connecticut	Ann Mahony	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
Delaware	Veronica Munson	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
District of Columbia	Veronica Munson	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
Florida	Brandon Johnson, Interim	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
Georgia	Brandon Johnson	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
Hawaii	Greg Grass	(240) 276-2919	(240) 276-2900	Greg.Grass@samhsa.hhs.gov
Idaho	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	Theresa.Mitchell@samhsa.hhs.gov
Illinois	Lisa Creatura	(240) 276-2821	(240) 276-2900	Lisa.Creatura@samhsa.hhs.gov
Indiana	Lisa Creatura	(240) 276-2821	(240) 276-2900	Lisa.Creatura@samhsa.hhs.gov
Iowa	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	Cheryl.Gallagher@samhsa.hhs.gov
Kansas	Carol Coley	(240) 276-2892	(240) 276-2900	Carol.Coley@samhsa.hhs.gov
Kentucky	Veronica Munson, Interim	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
Louisiana	Melissa Rael	(240) 276-2903	(240) 276-2900	Melissa.Rael@samhsa.hhs.gov
Maine	Ann Mahony	(240)-276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
Maryland	Veronica Munson	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
Massachusetts	Ann Mahony	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
Michigan	Lisa Creatura	(240) 276-2821	(240) 276-2900	Lisa.Creatura@samhsa.hhs.gov
Minnesota	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	Cheryl.Gallagher@samhsa.hhs.gov
Red Lake Band of the Chippewa (MN)	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	Cheryl.Gallagher@samhsa.hhs.gov
Mississippi	Veronica Munson, Interim	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
Missouri	Carol Coley	(240) 276-2892	(240) 276-2900	Carol.Coley@samhsa.hhs.gov
Montana	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	Theresa.Mitchell@samhsa.hhs.gov
Nebraska	Carol Coley	(240) 276-2892	(240) 276-2900	Carol.Coley@samhsa.hhs.gov
Nevada	Greg Grass	(240) 276-2919	(240) 276-2900	Greg.Grass@samhsa.hhs.gov
New Hampshire	Ann Mahony	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
New Jersey	Veronica Munson	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
New Mexico	Melissa Rael	(240) 276-2903	(240) 276-2900	Melissa.Rael@samhsa.hhs.gov
New York	Veronica Munson	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
North Carolina	Brandon Johnson	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
North Dakota	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	Cheryl.Gallagher@samhsa.hhs.gov
Ohio	Lisa Creatura	(240) 276-2821	(240) 276-2900	Lisa.Creatura@samhsa.hhs.gov
Oklahoma	Carol Coley	(240) 276-2892	(240) 276-2900	Carol.Coley@samhsa.hhs.gov
Oregon	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	Theresa.Mitchell@samhsa.hhs.gov
Pennsylvania	Veronica Munson	(240) 276-2901	(240) 276-2900	Veronica.Munson@samhsa.hhs.gov
Rhode Island	Ann Mahony	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
South Carolina	Brandon Johnson	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
South Dakota	Cheryl Gallagher, Interim	(240) 276-1615	(240) 276-2900	Cheryl.Gallagher@samhsa.hhs.gov
Tennessee	Ann Mahony, Interim	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
Texas	Melissa Rael	(240) 276-2903	(240) 276-2900	Melissa.Rael@samhsa.hhs.gov
Utah	Greg Grass	(240) 276-2919	(240) 276-2900	Greg.Grass@samhsa.hhs.gov
Vermont	Ann Mahony	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
Virginia	Brandon Johnson	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
Washington	Theresa Mitchell Hampton	(240) 276-1365	(240) 276-2900	Theresa.Mitchell@samhsa.hhs.gov
West Virginia	Ann Mahony, Interim	(240) 276-2969	(240) 276-2900	Ann.Mahony@samhsa.hhs.gov
Wisconsin	Lisa Creatura	(240) 276-2821	(240) 276-2900	Lisa.Creatura@samhsa.hhs.gov
Wyoming	Greg Grass	(240) 276-2919	(240) 276-2900	Greg.Grass@samhsa.hhs.gov
American Samoa	Steven Shapiro	(240) 276-2908	(240) 276-2900	Steven.Shapiro@samhsa.hhs.gov
Commonwealth of the Northern Mariana Islands	Steven Shapiro	(240) 276-2908	(240) 276-2900	Steven.Shapiro@samhsa.hhs.gov
Guam	Steven Shapiro	(240) 276-2908	(240) 276-2900	Steven.Shapiro@samhsa.hhs.gov
Republic of the Marshall Islands	Steven Shapiro	(240) 276-2908	(240) 276-2900	Steven.Shapiro@samhsa.hhs.gov
Federated States of Micronesia	Steven Shapiro	(240) 276-2908	(240) 276-2900	Steven.Shapiro@samhsa.hhs.gov
Republic of Palau	Steven Shapiro	(240) 276-2908	(240) 276-2900	Steven.Shapiro@samhsa.hhs.gov
Commonwealth of Puerto Rico	Brandon Johnson	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov
U.S. Virgin Islands	Brandon Johnson	(240) 276-2889	(240) 276-2900	Brandon.Johnson@samhsa.hhs.gov

Substance Abuse and Mental Health Services Administration Center For Substance Abuse Prevention Division of State Programs Division of State Programs Telephone (240) 276-2550 Substance Abuse Prevention and Treatment Block Grant Program State Project Officer Directory
State	Project Officers	Telephone	Facsimile	E-Mail
Alabama	Donna Simms- d’Almeida	(240) 276-2586	(240) 276- 2560	Donna.SimmsdAlmeida@samhsa.hhs.gov
Alaska	Allen Ward	(240) 276- 2444	(240) 276- 2560	Allen.Ward@samhsa.hhs.gov
Arizona	Mary Joyce Pruden	(240) 276- 2582	(240) 276- 2560	Maryjoyce.Pruden@samhsa.hhs.gov
Arkansas	William Reyes	(240) 276-1406	(240) 276- 2560	William.Reyes@samhsa.hhs.gov
California	Mary Joyce Pruden	(240) 276-2582	(240) 276- 2560	Maryjoyce.Pruden@samhsa.hhs.gov
Colorado	William Reyes	(240) 276-1406	(240) 276- 2560	William.Reyes@samhsa.hhs.gov
Connecticut	Andrea Harris	(240) 276-2441	(240) 276- 2560	Andrea.Harris@samhsa.hhs.gov
Delaware	Jamila Davis	(240) 276- 1429	(240) 276- 2560	Jamila.Davis@samhsa.hhs.gov
District of Columbia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276- 2560	Donna.SimmsdAlmeida@samhsa.hhs.gov
Florida	Kevin Chapman	(240) 276- 2584	(240) 276- 2560	Kevin.Chapman@samhsa.hhs.gov
Georgia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276- 2560	Donna.SimmsdAlmeida@samhsa.hhs.gov
Hawaii	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Idaho	Allen Ward, Interim	(240) 276- 2444	(240) 276- 2560	Allen.Ward@samhsa.hhs.gov
Illinois	Tonia Gray	(240) 276-2492	(240) 276- 2560	Tonia.Gray@samhsa.hhs.gov
Indiana	Tonia Gray	(240) 276-2492	(240) 276- 2560	Tonia.Gray@samhsa.hhs.gov
Iowa	Jamila Davis	(240) 276-1429	(240) 276- 2560	Jamila.Davis@samhsa.hhs.gov
Kansas	William Reyes	(240) 276-1406	(240) 276- 2560	William.Reyes@samhsa.hhs.gov
Kentucky	Kevin Chapman	(240) 276- 2584	(240) 276- 2560	Kevin.Chapman@samhsa.hhs.gov
Louisiana	Kevin Chapman	(240) 276-2584	(240) 276- 2560	Kevin.Chapman@samhsa.hhs.gov
Maine	Jamila Davis	(240) 276- 1429	(240) 276- 2560	Jamila.Davis@samhsa.hhs.gov
Maryland	Flo Dwek	(240) 276-2574	(240) 276- 2560	Flo.Dwek@samhsa.hhs.gov
Massachusetts	Flo Dwek	(240) 276-2574	(240) 276- 2560	Flo.Dwek@samhsa.hhs.gov
Michigan	Tonia Gray	(240) 276-2492	(240) 276- 2560	Tonia.Gray@samhsa.hhs.gov
Minnesota	Allen Ward, Interim	(240) 276-2444	(240) 276- 2560	Allen.Ward@samhsa.hhs.gov
Red Lake Band of the Chippewa (MN)	Allen Ward, Interim	(240) 276-2444	(240) 276- 2560	Allen.Ward@samhsa.hhs.gov
Mississippi	Kevin Chapman	(240) 276- 2584	(240) 276- 2560	Kevin.Chapman @samhsa.hhs.gov
Missouri	Tonia Gray	(240) 276- 2492	(240) 276- 2560	Tonia.Gray@samhsa.hhs.gov
Montana	William Reyes	(240) 276- 1406	(240) 276- 2560	William.Reyes@samhsa.hhs.gov
Nebraska	William Reyes	(240) 276-1406	(240) 276- 2560	William.Reyes@samhsa.hhs.gov
Nevada	Mary Joyce Pruden	(240) 276-2582	(240) 276- 2560	Maryjoyce.Pruden@samhsa.hhs.gov
New Hampshire	Andrea Harris	(240) 276-2441	(240) 276- 2560	Andrea.Harris@samhsa.hhs.gov
New Jersey	Andrea Harris	(240) 276-2441	(240) 276- 2560	Andrea.Harris@samhsa.hhs.gov
New Mexico	Flo Dwek	(240) 276-2496	(240) 276- 2560	Flo.Dwek@samhsa.hhs.gov
New York	Andrea Harris	(240) 276-2441	(240) 276- 2560	Andrea.Harris@samhsa.hhs.gov
North Carolina	Donna Simms- d’Almeida	(240) 276-2586	(240) 276- 2560	Donna.SimmsdAlmeida@samhsa.hhs.gov
North Dakota	Allen Ward, Interim	(240) 276-2444	(240) 276- 2560	Allen.Ward@samhsa.hhs.gov
Ohio	Tonia Gray	(240) 276-2492	(240) 276- 2560	Tonia.Gray@samhsa.hhs.gov
Oklahoma	William Reyes	(240) 276-1406	(240) 276- 2560	Willaim.Reyes@samhsa.hhs.gov
Oregon	Mary Joyce Pruden	(240) 276-2582	(240) 276- 2560	Maryjoyce.Pruden@samhsa.hhs.gov
Pennsylvania	Jamila Davis	(240) 276- 1429	(240) 276- 2560	Jamila.Davis@samhsa.hhs.gov
Rhode Island	Jamila Davis	(240) 276- 1429	(240) 276- 2560	Jamila.Davis@samhsa.hhs.gov
South Carolina	Kevin Chapman	(240) 276- 2584	(240) 276- 2560	Kevin.Chapman@samhsa.hhs.gov
South Dakota	Allen Ward, Interim	(240) 276-2444	(240) 276- 2560	Allen.Ward@samhsa.hhs.gov
Tennessee	Kevin Chapman	(240) 276- 2584	(240) 276- 2560	Kevin.Chapman@samhsa.hhs.gov
Texas	Clarese Holden, Interim	(240) 276- 2579	(240) 276- 2560	Clarese.Holden@samhsa.hhs.gov
Utah	Andrea Harris, Interim	(240) 276- 2441	(240) 276- 2560	Andrea.Harris@samhsa.hhs.gov
Vermont	Andrea Harris	(240) 276-2441	(240) 276- 2560	Andrea.Harris@samhsa.hhs.gov
Virginia	Donna Simms- d’Almeida	(240) 276-2586	(240) 276- 2560	Donna.Simmsdalmeida@samhsa.hhs.gov
Washington	Mary Joyce Pruden	(240) 276-2582	(240) 276- 2560	Maryjoyce.Pruden@samhsa.hhs.gov
West Virginia	Jamila Davis	(240) 276- 1429	(240) 276- 2560	Jamila.Davis@samhsa.hhs.gov
Wisconsin	Tonia Gray	(240) 276-2492	(240) 276- 2560	Tonia.Gray@samhsa.hhs.gov
Wyoming	Mary Joyce Pruden	(240) 276-2582	(240) 276- 2560	Maryjoyce.Pruden@samhsa.hhs.gov
American Samoa	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Guam	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Commonwealth of the Northern Mariana Islands	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Republic of the Marshall Islands	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Federated States of Micronesia	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Republic of Palau	Damaris Richardson	(240) 276- 2437	(240) 276- 2560	Damaris.Richardson@samhsa.hhs.gov
Commonwealth of Puerto Rico	Clarese Holden	(240) 276-2579	(240) 276- 2560	Clarese.Holden@samhsa.hhs.gov
U.S. Virgin Islands	Clarese Holden	(240) 276-2579	(240) 276- 2560	Clarese.Holden@samhsa.hhs.gov

Appendix B

FY 2011 Allocation Table for SAPT Block Grant

and

List of HIV Designated States

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Appendix B

FY 2011 Allocation Table for SAPT Block Grant

and

List of HIV Designated States

Designated States1, 2 for FY 2011 SAPT Block Grant Uniform Application
State3	Rate4	FY 2011 SAPTBG5	FY 1991 ADMSBG6	% Change1991-2011	HIV Set-Aside
Alabama	8.4	$23,850,008	$12,409,695	92%
Alaska	4.7	$4,796,474	$2,449,664	96%
Arizona	9.2	$34,764,203	$13,840,593	151%
Arkansas	6.9	$13,335,211	$4,807,518	177%
California	13.5	$250,794,726	$130,425,411	92%	$12,539,736
Colorado	7.3	$24,858,461	$13,956,718	78%
Connecticut	15.1	$16,808,904	$13,882,960	21%	$840,445
Delaware	19.8	$6,669,716	$3,148,031	112%	$333,486
District of Columbia	148.1	$6,669,716	$4,790,552	39%	$333,486
Florida	21.7	$98,102,522	$47,792,540	105%	$4,905,126
Georgia	19.7	$50,524,018	$17,701,223	184%	$2,526,201
Hawaii	6.1	$7,171,197	$4,590,998	56%
Idaho	1.5	$6,907,466	$2,173,396	217%
Illinois	10.5	$69,873,891	$48,009,708	45%	$3,493,695
Indiana	5.2	$33,308,207	$14,663,226	126%
Designated States1,2 for FY 2011 SAPT Block Grant Uniform Application
State3	Rate4	FY 2011 SAPTBG5	FY 1991 ADMSBG6	% Change1991-2011	HIV Set-Aside
Iowa	2.5	$13,524,616	$8,582,512	57%
Kansas	4.8	$12,291,614	$5,948,610	106%
Kentucky	6.9	$20,665,068	$11,290,513	82%
Louisiana	20.5	$25,850,751	$17,671,416	46%	$1,292,538
Maine	3.5	$6,669,716	$2,860,348	130%
Maryland	24.8	$31,980,001	$22,705,061	40%	$1,599,000
Massachusetts	9.5	$34,030,730	$26,059,220	30%
Michigan	6.2	$57,899,122	$40,890,802	41%
Minnesota	3.8	$23,968,851	$14,843,236	46%
Red Lake-Chippewa (MN)		$590,744	$390,000	51%
Mississippi	12.1	$14,258,225	$4,749,463	199%	$712,911
Missouri	9.2	$26,158,458	$16,984,801	53%
Montana	2.6	$6,669,716	$1,940,827	240%
Nebraska	4.5	$7,892,928	$4,662,147	69%
Nevada	13.1	$13,751,877	$4,317,190	198%	$687,594
New Hampshire	3.9	$6,669,716	$1,980,819	233%
New Jersey	13.4	$46,941,463	$35,398,346	32%	$2,347,073
New Mexico	5.7	$8,714,908	$4,209,623	106%
New York	24.9	$115,513,516	$93,451,518	23%	$5,775,676
North Carolina	11.3	$38,620,261	$16,092,236	139%	$1,931,013
North Dakota	1.3	$5,321,380	$1,708,762	201%
Ohio	6.1	$66,661,413	$38,367,574	73%
Designated States1,2 for FY 2011 SAPT Block Grant Uniform Application
State3	Rate4	FY 2010 SAPTBG5	FY 1991 ADMSBG6	% Change1991-2011	HIV Set-Aside
Oklahoma	7.3	$17,714,206	$8,250,691	114%
Oregon	6.4	$16,861,926	$10,323,828	57%
Pennsylvania	14.1	$59,087,858	$46,860,078	26%	$2,954,393
Rhode Island	6.2	$6,669,716	$4,952,253	33%
South Carolina	16.8	$20,574,947	$9,718,124	111%	$1,028,747
South Dakota	1.9	$4,920,793	$1,893,408	151%
Tennessee	10.7	$29,748,417	$14,221,946	108%	$1,487,421
Texas	12.4	$135,987,493	$62,406,552	117%	$6,799,375
Utah	2.6	$17,134,976	$7,325,996	133%
Vermont	1.0	$5,261,374	$1,907,282	166%
Virginia	8.2	$43,088,812	$21,505,683	100%
Washington	6.6	$34,978,304	$17,928,552	94%
West Virginia	4.2	$8,710,435	$3,501,025	151%
Wisconsin	3.6	$27,078,689	$18,849,237	36%
Wyoming	2.5	$3,418,788	$972,873	239%
Subtotal, States		$1,664,316,528	$940,364,785		$52,784,139
American Samoa		$331,855
Guam		$896,699
Republic of the Marshall Islands		$294,488
Designated States1,2 for FY 2010 SAPT Block Grant Uniform Application
State3	Rate4	FY 2011 SAPTBG5	FY 1991 ADMSBG6	% Change1991-2011	HIV Set-Aside
Federated States of Micronesia		$619,838
Commonwealth of the Northern Mariana Islands		$400,959
Republic of Palau		$110,804
Puerto Rico	21.5	$22,061,150	$12,608,307	73%	$1,093,456
Virgin Islands, U.S.	31.4	$629,129	$520,633	17%	$30,344
Subtotal, Territories		$25,344,922	$13,128,940		$1,123,800
Total States/Territories		$1,689,661,450			$53,907,939
SAMHSA Set-Aside		$88,929,550
Total, SAPTBG		$1,778,591,000	$953,493,725

1. The term “designated State” means any State whose rate of cases of acquired immune deficiency syndrome (AIDS) is 10 or more such cases per 100,000 individuals (as indicated by the number of such cases reported to and confirmed by the Centers for Disease Control and Prevention (CDC) for the most recent calendar year for which the data are available (See 45 C.F.R. §96.128(b).

2. As soon as FY 2011 applicable budgetary and epidemiological data are available this table will be updated.

3. Total of 20 “designated States” (including District of Columbia, Puerto Rico, and the Virgin Islands).

4. The most recent data published prior to October 1, 2009 by the CDC is Table 16, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through June 2007-United States, HIV/AIDS Surveillance Report 2007 Vol. 19, U.S. Department of Health and Human services, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS, Prevention, Surveillance, and Epidemiology. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 or 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table16.htm

5. Source: FY 2011 Justification of Estimates for Appropriations Committees.

6. FY 1991 is the base year to determine amount of set-aside (Source: Section 1924 (b)(4) of the Public Health Service Act).

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1 ^?The term State is used to refer to all the States and territories eligible to receive Substance Abuse Prevention and Treatment Block Grant funds (See 42 U.S.C. §300x-64 and 45 C.F.R. §96.121).

2 See Section III.1 for Intended Use Plan narratives

3 The most recent data published prior to October 1, 2009 by the CDC is Table 16, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through June 2007-United States, HIV/AIDS Surveillance Report 2007 Vol. 19, U.S. Department of Health and Human services, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS, Prevention, Surveillance, and Epidemiology. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 or 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table16.htm

4

^? The most recent data published prior to October 1, 2007 by the CDC is Table 14, Reported AIDS cases and annual rates (per 100,000 population), by area of residence and age category, cumulative through 2005─United States. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2005 (Vol. 17). Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005. The HIV/AIDS Surveillance Report is published annually by the Division of HIV/AIDS Prevention–Surveillance, and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia. Single copies of the report are available through the CDC National Prevention Information Network, 1-800-458-5231 or 301-562-1098 or http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/table14.htm

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