Form Section B: PDO Section B: PDO Section B: PDO

‎PDO/Naloxone Unique Questions

Grants for the Prevention of Prescription Drug / Opioid Overdose (PDO)

Unique Questions - PDO/Naloxone Distribution Program

Instructions for Using the Unique Questions for the PDO/Naloxone Distribution Program

In this tool, all PDO-specific substitute or additional text is captured in RED. All additional PDO-specific items are captured in RED tables. These RED text blocks and items should be inserted into the Division of State Programs- Management Reporting Tool (DSP-MRT). The Technical Notes found throughout the tool show where in the DSP-MRT the additional text or items should be inserted into the DSP-MRT Wireframes document. The Technical Notes also delineate which items are optional, removed, or substitutions for the PDO/Naloxone grant program.

Contact Information

ADD PARAGRAPH & ICON AFTER INTRODUCTORY TEXT IN DSP MRT

Partner organization is used to indicate any of the selected high-need community’s partners (e.g., law enforcement agencies, syringe exchange programs) that receive naloxone kits or training, or distribute naloxone drugs to laypersons through the grant. Note that the subrecipient may also be considered a partner organization if it will be providing these activities (e.g., distributing to laypersons) rather than simply engaging and coordinating with the other partner organizations. Exhibit 1 illustrates the involved levels and provides an example at each level.

Exhibit 1. Levels of Data Reporting

Oak County (served by Oak County Health Department) Example OC Police Department OC Syringe Exchange Program New Beginnings Treatment Agency

* Some grantees may not have subrecipients. Also, some subrecipients may serve more than one selected high-need community.

1. Grantee

Grantee Information

GATHERED IN DSP MRT – NO UNIQUE ITEMS

2. Community

Subrecipients and Selected High-Need Communities

GATHERED IN DSP MRT – NO UNIQUE ITEMS

3. Partner Org

Partner Organizations

Use this section to add or update partner organization information for each selected high-need community. Partner organizations are the entities receiving naloxone drugs or naloxone training (e.g., law enforcement agencies) or distributing to and training laypersons (e.g., syringe exchange programs).

In a later section of the progress report, you will be asked to report on naloxone drug distributed to these partner organizations, and the naloxone administration events reported by these partner organizations for this grant. Note that if the subrecipient for the selected high-need community will also be providing these activities (e.g., distributing to laypersons) rather than simply engaging and assisting the other partner organizations, you will need to enter the subrecipient as a partner organization here. Partner organization information will be carried over from one reporting period to the next.

Item	Type of Item/ Response Options	Technical Notes
High-Need Community	Dropdown list Community 1 Community 2 Etc.	The dropdown list is populated from the data the grantee enters in Section 1.2. The grantee will submit data for each community in this section by selecting a community from the dropdown list, entering and saving data, and then selecting the next community from the dropdown list.

Item	Type of Item/ Response Options	Technical Notes
In the SPARS data collection system, there will be an “Add” button for this section. Grantees will be able to click that button to add additional records as needed.
Partner organization name	Free text
Sector	Checklist (mark all that apply): Corrections Courts Emergency medical system (EMS) Emergency Medical Technician (EMT) Fire Departments Harm reduction agency Law enforcement Other social service organization Pharmacies Public health agencies Recovery community organization Shelters Substance use disorder treatment Syringe exchange programs Other (specify) ___________	Help Text: Some options may not be applicable per your grant. Contact your project officer with questions
Target ZIP codes of the partner organization’s service area	Clicking "Add" will add the entered value to the grid displayed below the field. Alternately, clicking on the "USPS ZIP Code Look-up" link will open a new window, directing the user to the following URL: https://tools.usps.com/go/ZipLookupAction!input.action. Clicking on the "Delete" icon beside a previously entered value will delete the selected value
Alternative:	Free text	If this partner organization targets an entire county (or counties), indicate the county name(s) here.

Needs Assessment

4. Grantee

Needs Assessment Upload

GATHERED IN DSP MRT – NO UNIQUE ITEMS

5. Grantee

Accomplishments and Barriers/Challenges

GATHERED IN DSP MRT – NO UNIQUE ITEMS

Capacity

6. Grantee

Membership

GATHERED IN DSP MRT – NO UNIQUE ITEMS

7. Grantee

Advisory Council and Other Workgroup Meetings

GATHERED IN DSP MRT – NO UNIQUE ITEMS

8. Grantee

Grantee Funding Resources

GATHERED IN DSP MRT – NO UNIQUE ITEMS

Grantee

Other Resources

>Leveraged Resources

Use this section to enter information regarding leveraging resources, including grantee-level opioid workgroups and grantee-level funding resources. Grantee is used to indicate the state/tribal entity/jurisdiction receiving the award.

Unless the information changes from one reporting period to another, this information only needs to be entered once per fiscal year. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/ Response Options	Technical Notes
Does a grantee-level workgroup exist in your state/tribal entity/jurisdiction addressing opioid issues (prescribing, misuse, treatment, overdose)?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed.
Does the opioid workgroup serve as your Advisory Council?	Radio buttons: Y/N	This item will only appear if Yes is selected for the first item in this section. Responses will be carried over across reporting periods. Grantees can edit if needed.
Does a grantee-wide strategic plan exist addressing opioid issues, including prevention of misuse, treatment, and overdose prevention?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed.
How are opioid prevention efforts integrated into the state-wide agenda for opioids?	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.
In what ways have you coordinated opioid funding streams in your state/tribal entity/jurisdiction?	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.
In what ways is your training curriculum informed by or congruent with the SAMHSA Opioid Overdose Prevention Toolkit?	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.

>Data Infrastructure

Use this section to enter information regarding data infrastructure and activities. Data infrastructure refers to a system or systems for collecting and disseminating data related to naloxone education trainings, distribution, and administration; and opioid overdose. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/Response Options	Technical Notes
Do you have a grantee-wide system or systems in place for collecting data on naloxone administrations?	Radio buttons: Y/N	Responses will be carried over across reporting periods. Grantees can edit if needed.
Which sectors report data into the grantee-wide system(s)?	Checklist (mark all that apply) Corrections Courts Emergency medical system (EMS) Emergency Medical Technician (EMT) Fire Departments Harm reduction agency Law enforcement Other social service organization Pharmacies Public health agencies Recovery community organization Shelters Substance use disorder treatment Syringe exchange programs Other (specify)_______	This item will only appear if Yes is selected for the previous item in this section. Responses will be carried over across reporting periods. Grantees can edit if needed.
During this reporting period, have you engaged in efforts to: …Enhance data infrastructure to track naloxone education trainings?	Radio buttons: Y/N
…Enhance data infrastructure to track naloxone distribution or administration?	Radio buttons: Y/N
… Enhance opioid overdose data infrastructure?	Radio buttons: Y/N
… Enhance access to existing opioid overdose data sources?	Radio buttons: Y/N
Did you provide naloxone or opioid-related data to local community stakeholders during this reporting period?	Radio buttons: Y/N

9. Grantee

10. Community

Training and Technical Assistance (TA)

This Section will use the DSP MRT items and structure however the unique text below needs to be added.

Please note that this section only includes trainings and technical assistance (TA) to enhance grantee/partner capacity, such as training around using project data collection systems, building community partnerships, and implementing media campaigns. This section does not include naloxone administration trainings or other types of trainings that are intended to influence outcomes (e.g., trainings related to opioid prescribing or medication-assisted treatment), as such trainings are recorded in the Implementation section of this progress report.

11. Grantee

Accomplishments and Barriers/Challenges

GATHERED IN DSP MRT – NO UNIQUE ITEMS

2. Community

3. Grantee

Behavioral Health Disparities

GATHERED IN DSP MRT – NO UNIQUE ITEMS

Implementation

1. Grantee

Accomplishments and Barriers/Challenges

GATHERED IN DSP MRT – NO UNIQUE ITEMS

2. Grantee

Promising Approaches and Innovations

GATHERED IN DSP MRT – NO UNIQUE ITEMS

Policy

Use this section to report information about state-level policies related to naloxone or similar drugs. Most of the information will be prepopulated based on publicly available, state-level information at the time of the grant award.¹ Please review for accuracy (to the best of your knowledge), and update this section when naloxone policies change in your state. Grantee is used to indicate the state/tribal entity/jurisdiction receiving the award from SAMHSA/CDC. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Grantee

>Naloxone Access Laws

Item	Type of Item/ Response Options	Technical Notes
Does the state/tribal entity/jurisdiction have a naloxone access law (legislation designed to improve access to naloxone?)	Radio buttons: Y/N	Prepopulated. If yes is checked, the items below will appear.

Prescribing and Dispensing Policies
Do prescribers have immunity for prescribing, dispensing, or distributing naloxone to a layperson? Civil Criminal Disciplinary		Radio buttons: Y/N for each type of immunity		Prepopulated, editable
Do dispensers (pharmacists) have immunity for prescribing, dispensing, or distributing naloxone drugs to a layperson? Civil Criminal Disciplinary		Radio buttons: Y/N for each type of immunity		Prepopulated, editable
Are prescriptions to third parties (e.g., family members, friends) authorized?		Radio buttons: Y/N		Prepopulated, editable
Are insurers required to pay for naloxone drugs dispensed to third parties?		Radio buttons: Y/N		Prepopulated, editable
Are insurers restricted from having a prior authorization policy for naloxone drugs prescriptions?		Radio buttons: Y/N		Prepopulated, editable
Is prescription by a standing order authorized?		Radio buttons: Y/N		Prepopulated, editable
[If yes] Is a statewide standing order in place?		Radio buttons: Y/N		Will only appear if item above is Yes. Information not available online, so will not be prepopulated
Do pharmacists have authority to initiate prescriptions for naloxone (prescriptive authority)?		Radio buttons: Y/N		Information not available online, so will not be prepopulated
Layperson Administration/Possession Policies
Is a layperson immune from liability when administering naloxone drugs? Civil Criminal	Radio buttons: Y/N for each type of immunity		Prepopulated, editable
Is participation in a naloxone education program required as a condition of immunity?	Radio buttons: Y/N		Prepopulated, editable

Grantee

>Good Samaritan Laws

Item	Type of Item/ Response Options	Technical Notes
Does the state have an overdose Good Samaritan law (legislation designed to reduce criminal concerns when a layperson summons aid during an overdose)?	Radio buttons: Y/N	Prepopulated. If yes is checked, the items below will appear.
What protection, if any, does the law provide from controlled substance possession laws? Protection from… Arrest Charge Prosecution	Radio buttons: Y/N for each type of protection	Prepopulated, editable
What protection, if any, does the law provide from drug paraphernalia laws? Arrest Charge Prosecution	Radio buttons: Y/N for each type of protection	Prepopulated, editable
Does the law provide protection from parole or probation violations?	Radio buttons: Y/N	Prepopulated, editable
Is reporting an overdose considered a mitigating factor in sentencing?	Radio buttons: Y/N	Prepopulated, editable
Does the law provide protection from outstanding warrants?	Radio buttons: Y/N	Prepopulated, editable

1. Community

>High-Need Community Policies/Protocols

Use this section to provide information about whether local naloxone standing orders, collaborative practice agreements, or other policies exist within each of your selected high-need communities. High-Need Community is used to indicate the grantee’s selected high-need communities. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/ Response Options	Technical Notes
Do any of your high-need communities have local naloxone standing orders, collaborative practice agreements, or other naloxone policies/ protocols?	Radio buttons: Y/N	Following 2 items are skipped if answer is No.

Item	Type of Item/ Response Options	Technical Notes
High-Need Community	Dropdown list Community 1 Community 2 Etc.	Dropdown list is populated from the data the grantee enters in Section 1.2. The grantee will submit data for each community in this section by selecting a community from the dropdown list, entering and saving data, and then selecting the next community from the dropdown list.

Item	Type of Item/ Response Options	Technical Notes
Please provide a brief description of the local policies/protocols in this community.	Free text	This item will appear for each selected community.

Naloxone Education and Other Opioid-Related Trainings

2. Community

>High-Need Community-Level Trainings

Use this section to report information on the naloxone education and other opioid-related trainings offered in each selected high-need community during the reporting period. These trainings can include group or individual trainings. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/ Response Options	Technical Notes
High-Need Community	Dropdown list Community 1 Community 2 Etc.	The dropdown list is populated from the data the grantee enters in Section 1.2. The grantee will submit data for each community in this section by selecting a community from the dropdown list, entering and saving data, and then selecting the next community from the dropdown list.

Item	Type of Item/ Response Options	Technical Notes
Type of community-level training(s) provided	Checklist (mark all that apply) Naloxone Administration Other Opioid-Related Trainings (e.g., opioid prescribing, naloxone co-prescribing or dispensing, communicating with patients, medication-assisted treatment)	If naloxone Admin is checked, the items in the “naloxone Administration Trainings” section of this table will appear. If Other Opioid-Related trainings is checked, the items in the “Other Opioid-Related Trainings” section of this table will appear.
Naloxone Administration Trainings
Which of the following audience(s) received naloxone trainings as part of the grant during this reporting period?	Checklist (mark all that apply) Professional first responders (e.g., law enforcement, Emergency Medical Services, fire department) Lay person and community organization staff (e.g., family/friend/at-risk individuals, substance use disorder treatment staff) Other individuals (e.g., correctional staff) (specify)

If you selected professional first responders as one of your audiences, then the following questions will appear.
What is the approximate duration of the professional first responder training?	Numerical	Include a text label next to the field that says “minutes.” Responses will be carried over across reporting periods. Grantees can edit if needed.
Number of professional first responder trainings provided during this reporting period	Numerical
Total number of professional first responders who participated in trainings during this reporting period	Numerical
Number of professional first responders who completed a post-survey	Numerical
Number of professional first responders completing post-surveys who reported feeling confident administering naloxone in case of an overdose	Numerical	Item will include a link to the recommended survey items, response options, and calculation instructions.
Number of professional first responders completing post-surveys who reported perceiving they had learned new information or skills as a result of the training	Numerical	Item will include a link to the recommended survey items, response options, and calculation instructions.
If layperson and community organization/agency staff is one of the selected audiences, then the following questions will appear.
What is the approximate duration of the layperson and community organization staff training?	Numerical	Include a text label next to the field that says “minutes.” Responses will be carried over across reporting periods. Grantees can edit if needed.

Naloxone Administration Trainings
Number of layperson and community staff trainings provided during this reporting period	Numerical
Total number of layperson and community staff who participated in trainings during this reporting period	Numerical
Number of layperson and community staff who completed a post-survey	Numerical
Number of layperson and community staff completing post-surveys who reported feeling confident administering naloxone drugs in case of an overdose	Numerical	Item will include a link to the recommended survey items, response options, and calculation instructions.
Number of layperson and community staff completing post-surveys who reported perceiving they had learned new information or skills as a result of the training	Numerical	Item will include a link to the recommended survey items, response options, and calculation instructions.
If you selected other individuals as one of your audiences, then the following questions will appear.
Please specify the other individuals.	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.
What is the approximate duration of the trainings for other individuals?	Free text (in case more than one “other” training audience is offered)	Responses will be carried over across reporting periods. Grantees can edit if needed.
Number of other individuals’ trainings provided during this reporting period	Numerical
Total number of other individuals who participated in trainings during this reporting period	Numerical
Number of other individuals who completed a post-survey	Numerical

Naloxone Administration Trainings
Number of other individuals completing post-surveys who reported feeling confident administering naloxone drugs in case of an overdose	Numerical	Item will include a link to the recommended survey items, response options, and calculation instructions.
Number of other individuals completing post-surveys who reported perceiving they had learned new information or skills as a result of the training	Numerical	Item will include a link to the recommended survey items, response options, and calculation instructions.
Other Opioid-Related Trainings
Audience of training(s)	Checklist (mark all that apply) Medical professionals (excluding pharmacists) Pharmacists Other (specify)
Please specify the other audience type.	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.
If medical professionals (excluding pharmacists) is one of the selected audiences, then the following questions will appear.
Focus/Topic(s) of training(s) for medical professionals (excluding pharmacists)	Free text
Number of trainings	Numerical
Total number of trainees	Numerical
If you selected pharmacists as one of your audiences, then the following questions will appear.
Focus/Topic(s) of training(s) for pharmacists	Free text
Number of trainings	Numerical
Total number of trainees	Numerical

Other Opioid-Related Trainings
If other is one of the selected audiences, then the following questions will appear.
Focus/Topic(s) of training(s) for other audiences	Free text
Number of trainings	Numerical
Total number of trainees	Numerical

3. Grantee

>Grantee-Level Trainings

If you provided any grantee-level naloxone administration or other opioid-related trainings, use this section to report the grantee-level trainings you provided during the reporting period. Examples of grantee-level trainings include a training delivered to all pharmacists attending a state pharmacy conference or a naloxone administration training provided to all state police officers at a statewide training. Remember that trainings provided to enhance community partner capacity to implement the grant are reported under Implementation. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/ Response Options	Technical Notes
Did you provide any grantee-level naloxone administration or opioid-related trainings during this reporting period?	Radio button: Y/N	If No is selected, they will not get the following items.
Type of grantee-level training(s) provided	Checklist (mark all that apply) Naloxone Administration Other Opioid-Related Training (e.g., opioid prescribing, naloxone co-prescribing or dispensing, communicating with patients, medication-assisted treatment)	If naloxone Admin is checked, the items in the “Naloxone Administration Trainings” section of the table will appear. If Other Opioid-Related trainings is checked, the items in the “Other Opioid-Related Trainings” section of the will appear.

Community

>Training Data Collection Information

Please provide information about the survey items you used to report trainee results.

Item	Type of Item/ Response Options	Technical Notes
Did your post-training surveys include SAMHSA/CDC’s preferred question related to respondents’ confidence, or did it include a different but similar item/s that addressed confidence?	Radio button: The preferred item/A similar item	Item will include a link to the recommended survey items, response options, and calculation instructions. Responses will be carried over across reporting periods. Grantees can edit if needed. If The preferred item is selected, the next item will be skipped.
Please provide the exact wording, including response options, of the survey question(s), as well as any information that would be helpful in understanding the data (e.g., which response option(s) were included in the reported percentage).	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.
Did your post-training surveys include SAMHSA/CDC’s preferred question related to respondents learned new information and skills, or did it include a different but similar item/s?	Radio button: The preferred item/A similar item	Item will include a link to the recommended survey items, response options, and calculation instructions. Responses will be carried over across reporting periods. Grantees can edit if needed. If The preferred item is selected, the next item will be skipped.
Please provide the exact wording, including response options, of the survey question(s), as well as any information that would be helpful in understanding the data (e.g., which response option(s) were included in the reported percentage).	Free text	Responses will be carried over across reporting periods. Grantees can edit if needed.

Please provide information about the data collection/management tool(s) you are using to track training data (such as a web-based data entry system) and any additional information that would be useful in understanding the training data you have provided.

Item	Type of Item
Information about your training data collection/management tool and any additional information.	Free text

Naloxone Distribution

Grantee

>Distribution Plan Upload

Use this section to upload and provide a brief description (if desired) about the Distribution Plan. Once uploaded, you will only update this section if revisions were made to the plan.

Item	Type of Item/ Response Options	Technical Notes
Upload the Distribution Plan.	Upload link(s)
Provide a brief description of the document you upload.	Free text

Grantee

>Costs

Use this section to report grant funds used to purchase naloxone during the reporting period. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/ Response Options	Technical Notes
Total amount of grant funds spent on the purchase of naloxone products during this reporting period.	Currency
Type of kit purchased. Of the total grant funds spent to purchase kits, what amount was spent on and how many of each type of kit were purchased?
Nasal spray kits, 2 mg (Adapt/Narcan)	Currency and Numerical		The currency fields in these items must total the amount reported in the total grant funds spent on purchasing kits.
Nasal spray kits, 4 mg (Adapt/Narcan)	Currency and Numerical

Injectable (intramuscular), .4 mg/10 ml vial kits (Hospira)	Currency and Numerical
Injectable (intramuscular), .4 mg/1 ml vial kits (Mylan or West-Ward)	Currency and Numerical
Injectable (intramuscular), 1 mg/2 ml vial kits (Aurum)	Currency and Numerical
Auto-injector kits (Kaleo/Evzio)	Currency and Numerical
Other kits	Currency and Numerical
Other kits (specify)	Free text	Specify the type of kit if any number reported in “other.”
Other kits	Currency and Numerical
Other kits (specify)	Free text	Specify the type of kit if any number reported in “other.”

Partner Org

>Kits Distributed to Partner Organizations

Use this section to report information regarding the distribution of naloxone kits to the selected high-need communities’ partner organizations. This includes distribution to partner organizations whose staff will be responsible for administering naloxone drugs (as in the case of law enforcement) and to partner organizations whose staff then distribute the naloxone drugs to family/friends/at-risk individuals (as may be the case with syringe exchange programs).

You will first select the high-need community for which you are reporting; once you select a community, the partner organizations specific to that community (entered in the Contact Information > Partner Organizations section) will appear in a dropdown list, and you will report distribution to each relevant partner organization.

Item	Type of Item/ Response Options	Technical Notes
High-Need Community	Dropdown list Community 1 Community 2 Etc.	The dropdown list is populated from the data the grantee enters in Section 1.2. The grantee will first select each community from the dropdown list in this item. Then, for each community, the grantee will select each partner organization for whom there is data to report from the next item and will enter data for those partner organizations.

Item	Type of Item/ Response Options	Technical Notes
Partner Organization	Dropdown list Partner Org. 1 Partner Org. 2 Etc.	The dropdown list is populated from the data the grantee entered for this community in Section 1.3. The grantee will submit data for at least one partner organization in this section by selecting a partner organization from the dropdown list, entering and saving data, and then selecting the next partner organization from the dropdown list. Grantees may not enter data for all Partner Organizations in sub-section 6.5.3.

Item	Type of Item/ Response Options	Technical Notes
In the SPARS data collection system, the grantee must enter the data in this section for each partner organization reported in the Contact Information Section by clicking on each community and partner organization in the two nested items above.
Total number of kits distributed to this organization using funds from this grant	Numerical
Type of kit distributed. Of the total kits distributed using funds from this grant, how many were:
Nasal spray kits, 2 mg (Adapt/Narcan)	Numerical	These items must total the number reported in the total number of kits distributed.
Nasal spray kits, 4 mg (Adapt/Narcan)	Numerical
Injectable (intramuscular), .4 mg/10 ml vial kits (Hospira)	Numerical
Injectable (intramuscular), .4mg/1ml vial kits (Mylan or West-Ward)	Numerical
Injectable (intramuscular), 1 mg/2 ml vial kits (Aurum)	Numerical
Auto-injector kits (Kaleo/Evzio)	Numerical
Other kits	Numerical
Other kits (specify)	Free text	Specify the type of kit if any number reported in “other.”
Other kits	Numerical
Other kits (specify)	Free text	Specify the type of kit if any number reported in “other.”
Total number of kits distributed to or procured by this organization using funds from other sources (if known)	Numerical and checkbox	The checkbox field is provided to allow grantees to indicate “Don’t know” if they are unable to get this information. Include a text label next to the checkbox that says “Don’t know.”

Please provide information about the data collection/management tool(s) or system(s) you are using to track distribution and any additional information that would be useful in understanding the data you have provided.

Item	Type of Item
Information about your distribution data collection/management tool and any additional information	Free text

Partner Org

Administration by Partner Organizations

Use this section to report information on the naloxone administrations reported during this reporting period by each of the partner organizations receiving naloxone or naloxone training from this grant. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Ideally, you will report all administration events reported by partner organizations including those using kits paid for by this grant and those using kits paid for by other funding sources. However, if you are not able to report events using kits paid for by other sources, you will be able to report just those using kits paid for with grant funds.

You will first select the high-need community for which you are reporting; once you select a community, the partner organizations specific to that community (entered in the Contact Information > Partner Organizations section) will appear in a dropdown list, and you will report naloxone administration data provided to you by each relevant partner organization.

Item	Type of Item/ Response Options	Technical Notes
High-Need Community	Dropdown list Community 1 Community 2 Etc.	Dropdown list is populated from the data the grantee enters in Section 1.2. The grantee will first select each community from the dropdown list in this item. Then, for each community, the grantee will select each partner organization for whom there is data to report from the next item and will enter data for those partner organizations.

Item	Type of Item/ Response Options	Technical Notes
Partner Organization	Dropdown list Partner Org. 1 Partner Org. 2 Etc.	Dropdown list is populated from the data the grantee entered for this community in Section 1.3. The grantee will submit data for at least one partner organization in this section by selecting a partner organization from the dropdown list, entering and saving data, and then selecting the next partner organization from the dropdown list. Grantees may not enter data for all Partner Organizations in sub-section 6.6.

Item

Type of Item/

Response Options

Technical Notes

In the SPARS data collection system, the grantee must enter the data in this section for each partner organization reported in the Contact Information Section by clicking on each community and partner organization in the two nested items above.

What type of opioid reversal drug are you administering?

Check boxes (select all that apply): Naloxone, Buprenorphine, Other

Are you reporting all administration events reported by this organization or only events using a kit paid for by this grant?

Radio button: All events/Only those paid for by grant

Total number of administration events

Numerical

Approximately what percentage of this organization’s kits were paid for using funds from this grant?

Percentage

This item only appears if they answer “All events” to the first item above.

Type of kit administered. Of the total administration events, how many were:

Nasal spray kits, 2 mg (Adapt/Narcan)	Numerical	These items must total the number reported in the total number of administration events.
Nasal spray kits, 4 mg (Adapt/Narcan)	Numerical
Injectable (intramuscular), .4 mg/10 ml vial kits (Hospira)	Numerical
Injectable (intramuscular), .4 mg/1 ml vial kits (Mylan or West-Ward)	Numerical
Injectable (intramuscular), 1 mg/2 ml vial kits (Aurum)	Numerical
Auto-injector kits (Kaleo/Evzio)	Numerical
Other kits	Numerical
Other types of kits (specify)	Free text	Specify the type of kit if any number reported in previous item.
Other kits	Numerical
Other kits (specify)	Free text	Specify the type of kit if any number reported in “other.”

Item

Type of Item/

Response Options

Technical Notes

Single or Multiple Dose. Of the total administration events, how many consisted of:
A single dose/unit administered	Numerical	These items must total the number reported in the total number of administration events.
Multiple doses/units administered	Numerical

Location of administration. Of the total administration events, how many were administered… 

At a private residence

Numerical

These items must total the number reported in the total number of administration events.

In a public outdoor location (e.g., street, park), car, camp, or shelter

Numerical

At an indoor public place/business (including hotel/motel)

Numerical

At other types of locations

Numerical

Other types of location (specify)

Free text

Specify the type of location if any number reported in previous item.

Outcome of administration event. Of the total administration events, how many had the following outcome:

Please record the acute outcome (at the scene, at time of event); there is not an expectation that grantee will monitor outcome after patient has been transported to the ED

Overdose reversal

Numerical

These items must total the number reported in the total number of kits administered.

Death

Numerical

Event was likely not an opioid overdose

Numerical

Unknown outcome

Numerical

Please provide information about the data collection/management tool(s) or system(s) you are using to track administration and any additional information that would be useful in understanding the data you have provided.

Item	Type of Item
Information about your administration data collection/management tool and any additional information	Free text

Community

Grantee

Other Interventions

Use this section to report any other interventions you or your selected high-need communities implemented as part of this grant initiative during the reporting period. When you check Yes for any intervention, you will be asked to report who implemented the intervention—the grantee, any of the communities, or both. Please note: if you are reporting for a grant other than the PDO/Naloxone Distribution Grant, all references to “naloxone” should be considered “opioid overdose reversal drugs”.

Item	Type of Item/ Response Options	Technical Notes
Public Policy Interventions
Naloxone policy change effort	Radio buttons: Y/N	If Yes is checked, a prepopulated list including the grantee and communities will appear, and the grantee will mark all that apply for who implemented this intervention.
Pharmacy benefit strategy change (e.g., institute drug utilization reviews for high-dose opioids, add nasal naloxone to Medicaid formulary, remove prior authorization for naloxone)	Radio buttons: Y/N
Other policy intervention. If checked, a free text “specify” field will appear.	Radio buttons: Y/N
Community/Organizational Interventions
Collaboration with prescribers to obtain standing orders	Radio buttons: Y/N	If Yes is checked, a prepopulated list including the grantee and communities will appear, and the grantee will mark all that apply for who implemented this intervention.
Collaboration with pharmacies to distribute naloxone drugs	Radio buttons: Y/N
Solidifying partnerships with community entities experienced in naloxone distribution to laypeople	Radio buttons: Y/N
Solidifying partnerships with first responder agencies experienced in naloxone administration	Radio buttons: Y/N
Efforts to expand naloxone distribution to new community partners that have not received or distributed naloxone or related drugs previously	Radio buttons: Y/N
Enhancement of state or local cross-agency coordination of naloxone efforts	Radio buttons: Y/N
Other community/organizational intervention. If checked, a free text “specify” field will appear.	Radio buttons: Y/N
Information Dissemination for Prescribers/Pharmacists. Information dissemination includes dissemination of print and electronic materials, speaking engagements targeting prescribers/pharmacists, etc. This does not include naloxone education, which is captured in the Naloxone Education Trainings section.
Information dissemination to prescribers on naloxone co-prescribing and opioid overdose risk	Radio buttons: Y/N	If Yes is checked, a prepopulated list including the grantee and communities will appear, and the grantee will mark all that apply for who implemented this intervention.
Information dissemination to pharmacists on naloxone dispensing	Radio buttons: Y/N
Other effort related to information dissemination to prescribers/pharmacists. If checked, a free text “specify” field will appear.	Radio buttons: Y/N

Item	Type of Item/ Response Options	Technical Notes
Information Dissemination to Community Members
Media campaigns and community information dissemination about overdose, naloxone drugs, Good Samaritan laws	Radio buttons: Y/N	If Yes is checked, a prepopulated list including the grantee and communities will appear, and the grantee will mark all that apply for who implemented this intervention.
Messaging to pharmacy patients	Radio buttons: Y/N
Other effort related to information dissemination to community members. If checked, a free text “specify” field will appear.	Radio buttons: Y/N
Treatment and Recovery Access
Efforts or services to facilitate access to treatment and recovery	Radio buttons: Y/N	If Yes is checked, a prepopulated list including the grantee and communities will appear, and the grantee will mark all that apply for who implemented this intervention.
System changes for post-overdose or high-risk treatment/referral	Radio buttons: Y/N
Other effort related to treatment and recovery access. If checked, a free text “specify” field will appear.	Radio buttons: Y/N

Evaluation

Evaluation Plan

GATHERED IN THE MRT—NO UNIQUE ITEMS

Evaluation Report

GATHERED IN THE DSP MRT—NO UNIQUE ITEMS

Other Document Upload

GATHERED IN THE DSP MRT—NO UNIQUE ITEMS

Accomplishments and Barriers/Challenges

GATHERED IN THE DSP MRT—NO UNIQUE ITEMS

Sustainability

3. Grantee

Accomplishments and Barriers/Challenges

GATHERED IN THE DSP MRT—NO UNIQUE ITEMS

4. Community

5. Grantee

Overdose Outcomes

Use this section to report annual numbers of opioid-related overdose and overdose deaths. The numbers should be aggregated across all types of opioids, whether opioid pain relievers or illicit opioids (e.g., heroin). This section will only appear on the progress report due following the end of the federal fiscal year. You will report any data/time points that have become available prior to the report deadline.

Grantee is used to indicate the state/tribal entity/jurisdiction receiving the award from SAMHSA/CDC. High-Need Community is used to indicate the grantee’s selected high-need communities.

1. Grantee

Grantee-Level Overdose Data

First, you will report grantee-level adult (age 18+) data on deaths related to opioid overdose, and emergency department and other hospital visits involving opioid overdose. Note that grantee-level data refers to the entire state (or tribal area or jurisdiction). It does not refer to the aggregate of the selected high-need communities.

State grantees do not need to report information in the Population (Denominator) and Opioid Overdose Deaths fields, as these data will be pulled from CDC’s WONDER database. Tribal and jurisdiction grantees are asked to provide data for these fields.

Grantees are asked to report both emergency department and hospitalization data if available, but we are aware that some grantees may not have access to both or either type of data. Grantees may also report opioid overdose events from a different data source if desired, or if emergency department or hospitalizations data are not available.

Item	Type of Item/ Response Options	Technical Notes
2015	Link	Each year will appear as a link that takes the user to the data entry screens below, where grantees will provide data for each selected year. Next to each link, there will be a row of check boxes that indicates whether the data entry for that year has been completed for each of the data sources.
2016	Link
2017, etc.	Link

Demo-graphic group	Population (Denominator)	Opioid Overdose Deaths	Emergency Department Visits Involving Opioid Overdose	Hospitalizations Involving Opioid Overdose	Other Opioid Overdose Events (optional)
Total:
Total	State grantees do not need to provide these data, as they will be pulled from CDC WONDER		Numerical	Numerical	Numerical
Age:
15-24 yr	State grantees do not need to provide these data, as they will be pulled from CDC WONDER		Numerical	Numerical	Numerical
25-34 yr			Numerical	Numerical	Numerical
35-44 yr			Numerical	Numerical	Numerical
45-54 yr			Numerical	Numerical	Numerical
55-64 yr			Numerical	Numerical	Numerical
65+ yr			Numerical	Numerical	Numerical
Age Not Available			Numerical	Numerical	Numerical
Sex:
Males	State grantees do not need to provide these data, as they will be pulled from CDC WONDER		Numerical	Numerical	Numerical
Females			Numerical	Numerical	Numerical
Sex Not Available			Numerical	Numerical	Numerical

Note: The values entered for the age groups and the sexes must each total the values entered in the total line. Users will get an error message if the totals do not match.

Please provide information about the data source, any additional information that would be useful in understanding the overdose data you have provided, or both.

Data	Data Source and Additional Information
Data source: Population	Free text; State grantees do not need to provide this information
Data source: Opioid Overdose Deaths	Free text; State grantees do not need to provide this information
Data source: Emergency Department Visits Involving Opioid Overdose	Free text
Data source: Hospitalizations Involving Opioid Overdose	Free text
Data source: Other Opioid Overdose Events	Free text

2. Community

High-Need Community-Level Overdose Data

Next, you will report any community-level data that are available on opioid-related overdose deaths and events in your selected high-need communities.

Item	Type of Item/ Response Options	Technical Notes
High-Need Community	Dropdown list Community 1 Community 2 Etc.	The dropdown list is populated from the data the grantee enters in Section 1.2. The grantee will submit data for each community in this section by selecting a community from the dropdown list, entering and saving data, and then selecting the next community from the dropdown list.

Item	Type of Item/ Response Options	Technical Notes
2015	Link	Each year will appear as a link that takes the user to the data entry screens below for the given year. Next to each link there will be a row of check boxes that indicates whether the data entry for that year has been completed for each of the data sources.
2016	Link
2017, etc.	Link

Item	Population (Denominator)	Opioid Overdose Deaths	Emergency Department Visits Involving Opioid Overdose	Hospitalizations Involving Opioid Overdose	Other Opioid Overdose Events (optional)
Number	Numerical	Numerical	Numerical	Numerical	Numerical
Data source and any additional information	Free text	Free text	Free text	Free text	Free text

1 From the Network for Public Health Law (https://www.networkforphl.org/_asset/qz5pvn/legal-interventions-to-reduce-overdose.pdf) and the Policy Surveillance Program’s Law Atlas Project (http://lawatlas.org/query?dataset=laws-regulating-administration-of-naloxone#.U3YljijzDEU)

1