Form Community Outcomes Community Outcomes Community Outcomes Module

OMB No. 0930-0xxx

Expiration Date: xx/xx/xxxx

Public Burden Statement: 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 0930-0XXX.  Public reporting burden for this collection of information is estimated to average 4 hours 0 minutes per respondent, per year, 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, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Community Outcomes Data Fields

The table below provides the field name, help text, and drop-down values or response examples for each field for which grantees provide Community-Level Outcome Data.

Note: After the initial set of opening questions, grantees enter data in either the Survey Data section or the Administrative Data section, as relevant. Survey data rows are colored purple, and administrative data rows are colored blue.

Community Outcomes Fields

Field	Help Text	Drop-down Values or Example
Opening Fields that Appear for all Records
Subrecipient Name	Name of subrecipient receiving SPF SIG funding from the grantee	Drop-down list of subrecipients entered by grantee into the MRT
Priority	Please select the targeted priority for the measure you are reporting in this record. .	Drop-down list—Underage use of alcohol, Any use of alcohol, Heavy use of alcohol, Binge drinking, Any use of tobacco under age 18, Any use of tobacco 18 years of age or older, Non-medical use of prescription drugs, Any use of illegal drugs, Motor vehicle crashes, Crime, Dependence or abuse, Alcohol-related morbidity/mortality, Tobacco-related morbidity/mortality, Drug-related morbidity/mortality, Level of enforcement, Social access, Retail access, Norms, Perception of risk of detection of getting caught, Perception of risk and harm, Promotion, Individual factors, Price, Availability of pro-social activities, School Policies, Community and coalition development

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Indicator	Please select the indicator (or NOM) you are reporting in this record. Indicators are the more specific operationalization of the priority reported in the previous field, and may be either direct or indirect representations of a priority. Multiple indicators can be reported for a given priority, where applicable.	Drop-down list—30-day use, Age at first use, Disapproval of substance use, Family communication around drug use, Perceived risk/harm of use, Daily school attendance, Perception of workplace policy, Percentage of youth seeing (reading, watching, or listening to) a prevention message, ATOD-related suspensions and expulsions, Alcohol- and drug-related arrests, Alcohol-related traffic fatalities, Driving while under the influence of alcohol, Other
Other Indicator	If “Other” is selected for Indicator, the Other Indicator field will appear.	Text example—Prescription drug overdose deaths
Indicator Type	Specify whether the indicator is a Consumption, Consequence, or an Intervening Variable.	Drop-down list—Consumption, Consequence, Intervening Variable
Data Source Type	Indicate if you are reporting data from a survey or event data from an administrative surveillance system (for example, traffic data or hospital records).	Drop-down list—Survey Data, Event/Surveillance Data (all subsequent fields will differ based on your selection)
Fields That Appear if "Survey Data" Is Selected in the Data Source Type Field
Data Source	Insert the specific name of the survey in the Data Source Name field.	Drop-down list—State/Grantee student survey, State/Grantee adult survey, Local/Community student survey, Local/Community adult survey, YRBSS, BRFSS, NSDUH, PRIDE Survey, CTC Survey, Search Institute Survey, American Drug and Alcohol Survey, Other
Other Data Source	If “State/grantee student survey”, “State/grantee adult survey”, “local/community student survey”, “local/community adult survey”, "State/Grantee agency reporting system", "Local/Community agency reporting system" or “Other” is selected, the Other Data Source field will appear.	Text example—California Health Kids Survey

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Data Collection Date	Indicate the month and year in which the survey was conducted. If the data collection took multiple months, the month at the middle of the period should be reported. If it took an even number of months, the middle month closer to the end date should be reported. If multiple years of data were combined into a single estimate due to small sample size, insert the month and year of the most recent survey date and check "Multiple Year Pooled Estimate" below. [Note: Use of multiyear estimates must be preapproved by CSAP.]	Date field example—04/2013
Strategies implement prior to data collection?	Indicate whether any SPF strategies related to this priority had been implemented in this community before the data collection date (in other words, before the date the survey was administered).	Drop-down list—Yes, No
Start Date for Strategies Related to this Priority	Indicate during what quarter strategies related to this priority were first implemented in this community. This date refers to when the strategies were first implemented (for example, when direct services were provided) and does not include the planning stages. If multiple SPF strategies are being implemented in this community for the same priority, indicate the earliest implementation date among them.	Drop-down list—[List of quarters of each Federal fiscal year within the SPF SIG award period]
Measure: Source Item (exact wording)	Indicate for which survey item you are reporting data. Type out the source item verbatim, exactly as it appears on the survey instrument.	Text example #1—During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage? Text example #2—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?

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Measure: Response Options (exact wording)	Enter the response options for the survey item used for this measure. Type out the entire set of response options verbatim, exactly as they appear on the survey instrument. If applicable, include the associated codes for each response that was used in analyses. The coding schema is necessary for CSAP to understand reported outcomes that are means, medians, etc.	Text example #1—A number between 0 and 30 Text example #2—0 = no risk, 1 = slight risk, 2 = moderate risk, 3 = great risk, 99 = don’t know/can’t say
NOMs Item	Indicate whether the Source Item above qualifies as a NOMs item. In order for the Source Item to be considered a NOMs item, the item wording must match the approved NOMs item exactly, or have been approved by CSAP as an appropriate substitute NOM. Please refer to Section 3 for clarification.	Radio Buttons—Yes, No
Data Available for annual reporting?	Indicate whether the measure calculations above are annual measures.	Radio Buttons—Yes, No
Data Source or Measure Comments	Enter any explanatory comments needed to clarify any of the information provided in the fields related to Data Source and Measure.
Survey Population Information
Population from which Survey Sample is Drawn	Describe the population that the survey was designed to represent for this measure. Disaggregated populations are preferred. For example, if a survey is administered to grades 9 and 11 for a measure of high school drinking, grade 9 and grade 11 data should be reported separately when possible. In this case, grade 9 and grade 11 would be entered as separate populations.	Text example—Public school students in grade 9 attending school in County X.

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Population Age or Grade	Indicate whether the survey population was defined by age or grade level. If “Age” is chosen, you will be asked to enter the applicable age range by indicating minimum and maximum ages. If “Grade” is chosen, you will be asked to enter the applicable grade levels by indicating the grades involved in the survey data.	Drop-down list—Age, Grade
Survey Population Age Range Minimum	Insert the lower bound for the age range for the population represented by the survey.	Numeric field example—18
Survey Population Age Range Maximum	Insert the upper bound for the age range for the population represented by the survey. If the population age range is bound at the lower but not the upper end (for example, age 16 and over), then 99 should be entered as the maximum age.	Numeric field example—25
Survey Population Grade Range	Select the grade(s) of the population represented by the survey. When possible, data for each specified grade should be reported separately. If the survey was administered to grade 7 students only, then select 7. If the survey was administered to students in grades 9 and 11 and the current data being reported are for grade 9 students, then select 9. If the survey was administered to students in grades 9 and 11, and the data are being reported together, select both 9 and 11.	Check box list—K, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
N of Population	Enter the number of persons in the population from which the survey is drawn. For example, if the population is grade 9 students in County X, indicate the overall number of grade 9 County X students.	Numeric field example—9,076

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Survey Sample Information
Sampling Strategy	Indicate what type of sampling was used for the survey. Full census: All members of the target population are asked to participate. Convenience sample: The survey uses any members of the target population that are available or volunteer to participate (for example, intercept surveys at malls or schools, or Facebook surveys). Randomly selected sample: A sample of the target population is randomly selected to complete the survey. Targeted or purposive sample: Members of the target population are selected to participate based on characteristics deemed appropriate for the purpose of the survey.	Drop-down list—Full census, Convenience sample, Randomly selected sample, Targeted or purposive sample, Other
Specify other Sampling Strategy	If “Other” is selected for Sampling Strategy, the Other Sampling Strategy field will appear.	Text example—Quota sample
N of Sample	This pertains to the number of persons who were drawn for the survey sample, or the number of persons who were recruited for participation in the survey. For example, if a survey was mailed to 1,000 adults in the community, but only 300 completed and returned the survey, the N of Sample would be 1,000.	Numeric field example—1,000
Number of Respondents	This pertains to the number of persons who actually participated in the survey. For example, if a survey was mailed to 1,000 adults in the community, but only 300 completed and returned the survey, the Number of Respondents would be 300.	Numeric field example—300
Survey Sample or Respondent Comments or Concerns	Please comment on the information provided in the fields related to the survey sample and/or survey respondents. Please indicate any concerns about representativeness or response rates.

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Outcome Data Information for Survey Data
Reported Outcome for Survey Data	Provide a description of the specific outcome you will be reporting for this measure.	Text example—Percent of grade 9 students who used alcohol in the past 30 days
Calculated Value	Enter your actual numeric result. For example, you may enter "23.20" to indicate that 23.20% of the targeted population used alcohol in the past 30 days. If data to complete this field are not yet available, enter the following 10-digit “not yet available” code: 9999999999. Once data are available, please return to this field and enter the correct result.	Numeric field example—23.20
Value Type	Select from the drop-down list the type of number you will report in the Calculated Value field. If you are reporting a value type other than those listed, select "Other," and you will be asked to describe the value type.	Drop-down list—Percentage, Mean, Other
Other Value Type	If “Other” is selected for Value Type, the Other Value Type field will appear.	Text example—Median
Standard Error	Enter the standard error for the calculated value, computed in light of the sampling design used (for example, simple random or two-stage cluster design).	Numeric field example—4.64
Standard Deviation	Enter the standard deviation for the calculated value, computed in light of the sampling design used (for example, simple random or two-stage cluster design).	Numeric field example—8.42
95% Confidence Interval Lower Bound	Enter the lower bound of the 95% confidence interval of calculated value. This will typically be the calculated value minus about twice the standard error.	Numeric field example—13.92
95% Confidence Interval Upper Bound	Enter the lower bound of the 95% confidence interval of calculated value. This will typically be the calculated value plus about twice the standard error.	Numeric field example—32.48

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Actual number of valid responses for specific survey item	Indicate how many respondents provided a valid response (in other words, not missing) to the survey item. If data to complete this field are not yet available, please enter the following 10-digit “not yet available” code: 9999999999. Once data are available, please return to this field and enter the correct result.	Numeric field example —358
Possible number of valid responses for survey item	Indicate the possible number of valid responses for the specific survey item of interest. For example, if 130 adults responded to the survey item out of the 140 adults participating in the survey, the possible number of responses is 140. Consider skip patterns. For example, consider a case where the stem question asks whether the respondent has had alcohol in the past 30 days. Of the 140 survey respondents, 40 say “no” to this question and skip the following question (in other words, the specific survey item of interest). The other 100 say “yes” to the stem question and then are asked to answer the following question (in other words, the item of interest) about how many days in the past 30 days they have had alcohol. In this situation, the number of possible valid responses for the specific survey item would be 100.	Numeric field example—100
Validity Comments or Concerns	Provide any comments or concerns about whether the data accurately represent what is actually happening in the target population.

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Fields That Appear if "Event/Surveillance Data" Is Selected in the Data Source Type Field
Data Source	Insert the specific name of the administrative surveillance system you are using for this outcome.	Drop-down list— Fatality Analysis Reporting System (FARS), Uniform Crime Report (UCR), State/Grantee agency reporting system, Local/Community agency reporting system, Other
Other Data Source	If "State/Grantee agency reporting system", "Local/Community agency reporting system" or “Other” is selected, the Other Data Source field will appear.	Text example—Colorado Department of Transportation
Data Source Time Frame	Indicate the time frame during which data for this measure were collected.	Date fields example—10/1/2010–9/30/2011
Strategies implement prior to data collection?	Indicate whether any SPF strategies related to this priority had been implemented in this community before the data collection time period.	Radio Buttons—Yes, No
State Date for Strategies Related to this Priority	Indicate during what quarter strategies related to this priority were first implemented in this community. This date refers to when the strategies were first implemented (for example, when direct services were provided) and does not include the planning stages. If multiple SPF strategies are being implemented in this community for the same priority, indicate the earliest implementation date among them.	Drop-down list—[List of quarters of each Federal fiscal year within the SPF SIG award period]
Measure: Event Definition	Define the incident or event that comprises the operationalization of this indicator.	Text example—Alcohol-related motor vehicle fatalities involving drivers between the ages of 16 and 20.
Measure: Measure Calculation	Provide a description of how you will be calculating the measure, specifying all elements of the equation including numerators, denominators, divisors, and multipliers.	Text example—The number of alcohol-related traffic crashes in County X divided by the total number of traffic crashes in County X and multiplied by 100.

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
NOMs Item	Indicate whether the measure calculation above qualifies as a NOMs item. Note: In order for the measure calculation to be considered a NOMs item, the equation must match the approved NOMs equation exactly, or must be approved by CSAP as an appropriate substitute. Please refer to Section 3 for clarification.	Radio Buttons—Yes, No
Data Available for annual reporting?	Indicate whether the measure calculations above are annual measures.	Radio Buttons—Yes, No
Data Source or Measure Comments	Enter any explanatory comments needed to clarify any of the information provided in the fields related to Data Source and Measure.
Event Population Information
Population on which Event Data is Based	Describe the population that the event data were designed to represent for this measure.	Text example—All drivers in County X
Geographic unit of event	Indicate at what geographic level data are being reported. If Other is chosen, you will be asked to specify.	Drop-down list—State/Grantee, Subrecipient community, Service area, Other
Specify other geographic unit of event	If “Other” is selected for Geographic unit of event, the Other Geographic unit of event field will appear.	Text example—School District
Event Census Population Age Range Minimum	Insert the lower bound for the age range for the population specified. For example, if the outcome is alcohol-related motor vehicle crashes among young adults aged 18 to 25 years, the minimum would be 18.	Numeric field example—18
Event Census Population Age Range Maximum	Insert the upper bound for the age range for the population specified. If the population age range is bound at the lower but not the upper end (for example, age 16 and over), the maximum should be entered as 99.	Numeric field example—25

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
N of Population for Event Data	Estimated number of persons in the population from which the event data were collected. For example, if the event definition is alcohol-related motor vehicle crashes among young adults aged 18 to 25, then the N of the population would be the total number of drivers in the community between 18 and 25 years of age.	Numeric field example—8,765
Event Census Comments	Please comment on any of the information provided in the fields related to event data, including any concerns related to the event population.
Outcome Information for Event Data
Reported Outcome for Event Data	Provide a description of the specific outcome you will be reporting.		Text example—Percentage of motor vehicle fatalities in County X that were alcohol-related
Number of Events	Enter the number of times this event occurred in the community. If data to complete this field are not yet available, please enter the following 10-digit “not yet available” code: 9999999999. Once data are available, please return to this field and enter the correct result.		Numeric field example—14
Denominator Definition	Indicate how the reported outcome denominator is defined. This information should be consistent with the denominator listed in the Measure Calculation field.		Text example— Number of traffic crashes in County X
Denominator Value	Indicate the numeric value of the denominator for this reported outcome. This could be the number of persons for the specified population (for example, the number of drivers aged 16–25) or the total number of events on which the smaller subset of events is based (for example, the number of motor vehicle crashes). If data to complete this field are not yet available, please enter the following 10-digit “not yet available” code: 9999999999. Once data are available, please return to this field and enter the correct result.		Numeric field example—41

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Community Outcomes Fields (continued)

Field	Help Text	Drop-down Values or Example
Calculated Value	Enter your actual numeric result. For example, you may enter "30.20" to indicate that 30.20% of traffic crashes were alcohol related. If data to complete this field are not yet available, please enter the following 10-digit “not yet available” code: 9999999999. Once data are available, please return to this field and enter the correct result.	Numeric field example—30.20
Value Type	Select the type of number you have reported in the Calculated Value field. If you are reporting a value type other than those listed, select "Other," and you will be asked to describe the value type.	Drop-down list—Percentage, Rate per 1,000, Rate per 10,000, Rate per 100,000, Other
Other Value Type	If “Other” is selected for Value Type, the Other Value Type field will appear.

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