Form Community-Program Community-Program Community-Program Director Time 3

Form Approved

OMB No. 0930-####

Expiration Date: ##/##/##

Opioid State Targeted Response (STR) Evaluation

Community/Program Final Survey

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 three (3) hours 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Information and Directions

The purpose of this evaluation is to collect important grantee-level information about the implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) Opioid State Targeted Response (STR) grant. Questions in this survey focus on opioid use disorder* services and activities in your community/program using Opioid STR funds. Survey results will be aggregated to protect anonymity. It will take approximately three (3) hours to complete this survey, including the time for reviewing instructions, searching existing data sources, gathering the data needed to answer questions, and answering the questions. The survey does not need to be completed in one sitting, and will automatically save your answers as you enter them.

* Except where noted, all questions refer to prevention strategies, treatment and/or recovery services for opioid use disorder and related conditions (e.g., non-medical use of prescription pain medication, heroin users, one-time users, overdose) in your community/program one year since you completed the last survey in the spring of 2018. For the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) definition of opioid use disorder, please refer to the attached glossary.

Helpful Materials

Before completing the survey, it may be helpful to gather the following materials to help answer questions:

• Funding and budget information;

• Client-level service records;

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

• Evaluation findings and reports; and

• Organizational policies.

Background Information

1.

Did you complete the first community/program director survey in October 2017?
1	Yes
0	No GO TO QUESTION 3

2.

Has your position changed since that time?
1	Yes GO TO QUESTION 4
0	No GO TO QUESTION 6

Name
Work Street Address
Work Street Address
Work City, State, Zip
Work Phone
Work Email

4.

3.

What is your current employment position?

How long have you been in this position?
1	Years
2	Months

5.

Needs & Resources

This section focuses on your needs related to addressing opioid use disorder, and the resources available to your community/program to address opioid use disorder.

How much Opioid STR funding has your community/program received as of May 1, 2019?

$

6.

7.

How long will your community/program be funded through the Opioid STR grant?

8.

What services were being provided with the Opioid STR funds, as of May 1, 2019?

9.

What training was being provided with the Opioid STR funds, as of May 1, 2019?

How many full-time staff (clinical or other staff) were funded with Opioid STR funds, as of May 1, 2019?
		STAFF

11.

10.

Are any other activities being funded with Opioid STR funds, besides services/training or staff positions? If so, please specify below:

12.

Did your community/program receive any funding (other than the Opioid STR grant) that you used for opioid use disorder prevention strategies, treatment, and/or recovery services (including any federal, state, local, foundation, or private funding) between May 1, 2018 and April 30, 2019?
1	Yes GO TO QUESTION 13
0	No GO TO QUESTION 14

In the table below, indicate whether your community/program used each funding source for opioid use disorder prevention strategies, treatment, and/or recovery services between May 1, 2018 and April 30, 2019. Where possible, estimate the amount of funding your community/program has received and used for opioid use disorder prevention strategies, treatment, and/or recovery services between May 1, 2018 and April 30, 2019. (If grant program spans two fiscal years, please include funding received and used during both fiscal years.)

	Funding Source	Check if funding received	Total amount received		Total amount used for opioid prevention		Total amount used for opioid treatment, and/or recovery services
a.	SPF-Partnerships for Success (PFS) (SAMHSA)
b.	Substance Abuse Prevention and Treatment Block Grant (SAMHSA)
c.	SAMHSA Prescription Drug Overdose
d.	SAMHSA Medical-Assisted Treatment (MAT)
e.	CDC Prevention for States (PfS)
f.	CDC PDO Data-Driven Prevention Initiative (DDPI)
g.	SAMHSA Minority HIV/AIDS Initiative
h.	HRSA Rural Opioid Overdose Reversal (ROOR)
i.	Drug-Free Communities (DFC) grant
j.	Other Federal funds (Specify)
k.	Other state/tribal/jurisdiction funds (Specify)
l.	Other local government funds (Specify)
m.	Foundations/nonprofit organizations
n.	Corporate/business entities
o.	Individual donations/funding from fundraising events
p.	Other funding source (Specify)

13.

In the table below, indicate the total number of practitioners/staff in your community/program that provide prevention strategies, treatment, and/or recovery services for opioid use disorder as of May 1, 2019. Provide the data source(s) used to make this determination.

		For opioid use disorder, total number of practitioners/staff providing:
		Prevention strategies		Treatment and/or recovery services		Data Sources
a.	Physicians (excluding Psychiatrists)
b.	Psychiatrists
c.	Nurse Practitioners
d.	Psychologists
e.	Counselors
f.	Social Workers
g.	Paid Peer Specialists
h.	Volunteer Peer Specialists
i.	Others (Specify)
j.	Total

14.

In the table below, indicate the total number of providers in your community/program by category who have been trained to implement Medication Assisted Therapy (MAT) and the total number of providers in your community/program that provided MAT services as of May 1, 2019. Provide the data source(s) used to make this determination.

		Total number trained to provide MAT services as of May 1, 2019.		Total number providing MAT services as of May 1, 2019.		Data Sources
a.	Physicians (excluding Psychiatrists)
b.	Psychiatrists
c.	Nurse Practitioners
d.	Psychologists
e.	Counselors
f.	Social Workers
g.	Paid Peer Specialists
h.	Volunteer Peer Specialists
i.	Others (Specify)
j.	Total

15.

In the list below, identify A) if the following activities or programs were present in your community/program as of May 1, 2019, and B) whether your community/program expanded/enhanced/developed (or passed new legislation for) any of these activities or programs to address opioid use disorder between May 1, 2018 and April 30, 2019.

		A		B
		SELECT ONE		SELECT ALL THAT APPLY
		YES	NO	EXPANDED, ENHANCED, OR DEVELOPED/ PASSED USING OPIOID STR FUNDING	EXPANDED, ENHANCED, OR DEVELOPED/PASSED NOT USING OPIOID STR FUNDING	DID NOT EXPAND, ENHANCE OR DEVELOP/PASS
a.	Alcohol/Drug Testing Programs	1	0	1	2	0
b.	Alcohol/Drug-free Support Centers (e.g., clubhouses, drop in centers)	1	0	2	3	0
c.	Drug Take-Back Program	1	0	2	3	0
d.	Good Samaritan Law	1	0	2	3	0
e.	Governor’s Cabinet-Level Opioid Council/Team	1	0	2	3	0
f.	Integrated Community Care Models	1	0	2	3	0
g.	MAT Collaboratives	1	0	2	3	0
h.	Naloxone Access Laws	1	0	2	3	0
i.	Naloxone Distribution	1	0	2	3	0
j.	Opioid Prescribing Guidelines	1	0	2	3	0
k.	Opioid-Specific Community Trainings (e.g., first responders)	1	0	2	3	0
l.	Pain Management Services	1	0	2	3	0
m.	“Pill Mill” Laws	1	0	2	3	0
n.	Prescription Drug Monitoring Program	1	0	2	3	0
o.	Public Information Campaigns	1	0	2	3	0
p.	Substance Abuse Education	1	0	2	3	0
q.	Syringe Services Including Distribution Sites	1	0	2	3	0
r.	Telehealth	1	0	2	3	0
s.	Other (Specify)	1	0	2	3	0

16.

In the table below, select the area(s) in which your community/program has received training and technical assistance (T/TA) related to evaluating your efforts related to addressing opioid use disorder or whether T/TA was needed. We are specifically asking about guidance and T/TA related to evaluation activities that support and/or inform your response to the opioid abuse crisis between May 1, 2018 and April 30, 2019.

	Evaluation Training/Technical Assistance (T/TA) Areas	Did you receive T/TA in this area?
		MARK ONE FOR EACH ROW
		YES	NO	TA NOT NEEDED
a.	Completing of needs and resource assessment	1	0	2
b.	Using data for prevention, treatment, and/or recovery assessment, planning, and monitoring	1	0	2
c.	Using opioid addiction and epidemiology data, including risk and protective factors	1	0	2
d.	Developing an evaluation plan	1	0	2
e.	Finding data sources	1	0	2
f.	Collecting data	1	0	2
g.	Analyzing data	1	0	2
h.	Training staff about evaluation activities	1	0	2
i.	Building collaborative relationships with stakeholders and partner agencies	1	0	2
j.	Recruiting participants	1	0	2
k.	Conducting culturally competent evaluation	1	0	2
l.	Using data to understand and address health disparities	1	0	2
m.	Identifying evaluation goals and outcomes	1	0	2
n.	Other (specify)	1	0	2
o.	Other (specify)	1	0	2
p.	Other (specify)	1	0	2

17.

Data Use

This section focuses on data sources available to you and data management strategies used to address opioid use disorder.

19.

18.

Between May 1, 2018 and April 30, 2019, did your community/program collect data on how it implements prevention strategies that address opioid use disorders?
1	Yes
0	No

20.

Between May 1, 2018 and April 30, 2019, did your community/program collect data on how it implements treatment and/or recovery services interventions that address opioid use disorders?
1	Yes
0	No

21.

Between May 1, 2018 and April 30, 2019, did your community/program integrate opioid use disorder data (such as data that must be reported for the Opioid STR grant) with data from other agencies/groups to address opioid use disorder (e.g., data from pharmacies, poison control, first responders, etc.)?
1	Yes
0	No

Between May 1, 2018 and April 30, 2019, did your community/program share data with key stakeholders to address opioid use disorder?
1	Yes
0	No

23.

22.

In the table below, indicate whether the following community-level data were accessed as of May 1, 2019.

		Did your agency access community-level data?
		YES	NO	DON’T KNOW
a.	Rates of prescription drug misuse in the past 30 days	1	0	d
b.	Rates of lifetime prescription drug misuse (ever misused)	1	0	d
c.	Rates of high dose opioid prescribing (e.g., >90MME/day)	1	0	d
d.	Rates of opioid and benzodiazepine co-prescribing	1	0	d
e.	Rates of multiple prescriber episodes for opioid pain medication (as indicator of possible “doctor shopping”)	1	0	d
f.	Rates of multiple pharmacy episodes for opioid pain medication	1	0	d
g.	Mortality rates due to prescription drug/opioid overdose	1	0	d
h.	Emergency room visits/hospital admissions related to prescription drug/opioid use disorder	1	0	d
i.	Calls to poison center related to prescription drug/opioid use disorder	1	0	d
j.	Local data on geographic patterns of opioid overdoses	1	0	d
k.	Other (specify)	1	0	d

As of May 1, 2019, did your state/territory have an active Prescription Drug Monitoring Program (PDMP)?
1	Yes
0	No
d	Don’t know

24.

As of May 1, 2019, did your community/program have access to the PDMP to extract and use the data?
1	Yes
0	No
d	Don’t know

Did your community/program use PDMP data for the following purposes between May 1, 2018 and April 30, 2019?

		MARK ONE FOR EACH ROW
		YES	NO
a.	Help select and implement strategies and services to address opioid use disorder	1	0
b.	Extract and report rates of physician registration with prescription drug monitoring program	1	0
c.	Extract and report use of PDMP by physicians (number of queries; percentage of physicians making queries)	1	0
d.	Extract and report opioid prescribing rates	1	0

25.

ASK ONLY IF Q23 AND Q24 ARE “YES”

26.

Which PDMP data management and data use activity or activities has your community/program completed between May 1, 2018 and April 30, 2019? SELECT ALL THAT APPLY
1	Increased access to PDMP data among program staff
2	Increased usage of PDMP data among program staff
3	Increased the quality of PDMP data collected
4	Increased registration for the PDMP
5	Increased voluntary PDMP enrollment
6	Increased mandatory PDMP enrollment
7	Increased timely data upload by pharmacists to the PDMP
8	Integrated PDMPs with electronic health records
9	Integrated PDMPs with health information exchanges
10	Integration of PDMP data with vital records (e.g., deaths)
11	Increased reports to prescribers
12	Increased reports to dispensers
13	Increased reports to licensing boards
14	Any other efforts to improve data infrastructure (Specify)

Addressing Opioid Use Disorder

This section focuses on opioid use disorder prevention strategies, treatment, and/or recovery services available in your community/program.

27.

In the table below, provide the total number of a) people who received opioid use disorder-specific treatment services, and b) people who received opioid use disorder-specific recovery services in your community/program between May 1, 2018 and April 30, 2019. Please provide the total number who received these services as a result of Opioid STR funding.

		TOTAL
a.	Total number of people who received treatment services between May 1, 2018 and April 30, 2019.
b.	Total number of people who received recovery services between May 1, 2018 and April 30, 2019.

28.

In the table below, to the best of your knowledge, list all of the opioid-specific prevention strategies that your community/program has delivered between May 1, 2018 and April 30, 2019, the type of prevention strategy delivered, and the total number of people that received each strategy. Primary prevention refers to preventing new cases of opioid use disorder, while secondary prevention refers to identifying and treating opioid use disorder early on. Please indicate whether any of these strategies were a result of Opioid STR funding.

	Prevention strategy		Type of prevention strategy (Primary or Secondary)		Total number of people that received the strategy (if able to obtain)		Was strategy implemented using Opioid STR funding?
							SELECT ONE
							YES	NO
a.							1	0
b.							1	0
c.							1	0
d.							1	0
e.							1	0
f.							1	0

29.

In the table below, to the best of your knowledge, list all of the opioid-specific treatment services that your community/program has delivered between May 1, 2018 and April 30, 2019 and the total number of people that received each strategy. Please indicate whether any of these strategies were a result of Opioid STR funding.

	Treatment service		Total number of people that received the strategy (if able to obtain)	Was strategy implemented using Opioid STR funding?
				SELECT ONE
				YES	NO
a.				1	0
b.				1	0
c.				1	0
d.				1	0
e.				1	0
f.				1	0

In the table below, to the best of your knowledge, list all of the opioid-specific recovery services that your community/program has delivered between May 1, 2018 and April 30, 2019 and the total number of people that received each strategy. Please indicate whether any of these strategies were a result of Opioid STR funding.

	Recovery service		Total number of people that received the strategy (if able to obtain)	Was strategy implemented using Opioid STR funding?
				SELECT ONE
				YES	NO
a.				1	0
b.				1	0
c.				1	0
d.				1	0
e.				1	0
f.				1	0

30.

31.

In the table below, provide the total number of people within each demographic group who met DSM criteria for an opioid use disorder in your community/program between May 1, 2018 and April 30, 2019. For the DSM definition of opioid use disorder, please refer to the attached glossary.

AGE

17 and under

18-24

25-44

45-64

65 and over

TOTAL

Pregnant Women

TOTAL

M

F

M

F

M

F

M

F

M

F

M

F

a.

White

b.

Black or African American

c.

Native Hawaiian/ Other Pacific Islander

d.

Asian

e.

American Indian/ Alaskan Native

f.

More Than One Race Reported

g.

Unknown

h.

Not Hispanic or Latino

i.

Hispanic or Latino

32.

In the table below, provide the total number people within each demographic group who have received opioid use disorder treatment from your community/program between May 1, 2018 and April 30, 2019. Please only report the number of people who met DSM criteria for opioid use disorder.

AGE

17 and under

18-24

25-44

45-64

65 and over

TOTAL

Pregnant Women

TOTAL

M

F

M

F

M

F

M

F

M

F

M

F

a.

White

b.

Black or African American

c.

Native Hawaiian/Other Pacific Islander

d.

Asian

e.

American Indian/ Alaskan Native

f.

More Than One Race Reported

g.

Unknown

h.

Not Hispanic or Latino

i.

Hispanic or Latino

33.

In the table below, provide the total number of those people in the following specific target populations who have received opioid use disorder treatment from your community/program between May 1, 2018 and April 30, 2019. Please only report the number of people who met DSM criteria for opioid use disorder.

	Target Population	TOTAL
a.	Children (< 12)
b.	Adolescents (12-18)
c.	Adults aged 65+
d.	Military/Veterans
e.	LGBTQ
f.	People living in poverty
g.	People whose primary language is not English (LEP population)
h.	People with co-occurring mental illness
i.	Reentry Populations
j.	Homeless
k.	Other (specify)

34.

In the table below, provide the total number of people within each demographic group who received opioid use disorder recovery services from your community/program between May 1, 2018 and April 30, 2019. Please only report the number of people who met DSM criteria for opioid use disorder.

AGE

17 and under

18-24

25-44

45-64

65 and over

TOTAL

Pregnant Women

TOTAL

M

F

M

F

M

F

M

F

M

F

M

F

a.

White

b.

Black or African American

c.

Native Hawaiian/ Other Pacific Islander

d.

Asian

e.

American Indian/ Alaskan Native

f.

More Than One Race Reported

g.

Unknown

h.

Not Hispanic or Latino

i.

Hispanic or Latino

35.

For the Opioid STR funding period between May 1, 2018 and April 30, 2019, identify the opioid use disorder treatment and/or recovery services that your community/program: (1) has not implemented; (2) implemented prior to the grant and expanded or enhanced using non-Opioid-STR funding; (3) implemented using Opioid STR funding; or (4) implemented prior to the grant and expanded or enhanced using Opioid STR funding. Where possible, estimate the number of new cases (i.e., individuals who had not previously received service)
you served with these services using Opioid STR funding between May 1, 2018 and April 30, 2019.

		MARK ONE FOR EACH ROW
		NOT IMPLEMENTED	EXPANDED/ ENHANCED USING NON-OPIOID STR FUNDING	IMPLEMENTED USING OPIOID STR FUNDING	EXPANDED/ ENHANCED USING OPIOID STR FUNDING	# NEW CASES
PREVENTION CONTINUUM OF CARE
a.	Primary or Secondary Prevention (e.g., universal school-based prevention)	1	2	3	4
b.	Outreach, Information, and Referral	1	2	3	4
c.	Screening Brief Intervention and Referral to Treatment (SBIRT)	1	2	3	4
d.	Early Intervention (e.g., .5 ASAM level of care)	1	2	3	4
TREATMENT CONTINUUM OF CARE
e.	Detoxification	1	2	3	4
f.	Outpatient (e.g., treatment that occurs once a week in an outpatient setting)	1	2	3	4
g.	Intensive Outpatient	1	2	3	4
h.	Day Treatment	1	2	3	4
i.	Inpatient/Hospital (Other Than Detox)	1	2	3	4
RECOVERY CONTINUUM OF CARE
j.	Continuing Care (e.g., step-down treatment services)	1	2	3	4
k.	Practitioner Recovery Supports	1	2	3	4
l.	Peer Recovery Support Services	1	2	3	4

35.

For the Opioid STR funding period between May 1, 2018 and April 30, 2019, identify the opioid use disorder treatment and/or recovery services that your community/program: (1) has not implemented; (2) implemented prior to the grant and expanded or enhanced using non-Opioid-STR funding; (3) implemented using Opioid STR funding; or (4) implemented prior to the grant and expanded or enhanced using Opioid STR funding. Where possible, estimate the number of new cases (i.e., individuals who had not previously received service) you served with these services using Opioid STR funding between May 1, 2018 and April 30, 2019.

		MARK ONE FOR EACH ROW
		NOT IMPLEMENTED	EXPANDED/ ENHANCED USING NON-OPIOID STR FUNDING	IMPLEMENTED USING OPIOID STR FUNDING	EXPANDED/ ENHANCED USING OPIOID STR FUNDING	# NEW CASES
SPECIFIC SERVICE COMPONENTS w/in CONTINUUM OF CARE
Pharmacological Interventions
m.	Methadone	1	2	3	4
n.	Buprenorphine	1	2	3	4
o.	Naltrexone (Oral)	1	2	3	4
p.	Naltrexone (Extended-release injectable)	1	2	3	4
Treatment Services
q.	Case Management	1	2	3	4
r.	Co-Occurring Treatment Services (i.e., mental health and substance abuse services)	1	2	3	4
s.	Infectious Disease (e.g., HIV/AIDS, Hepatitis) Services	1	2	3	4
t.	Trauma-focused/informed Services	1	2	3	4
u.	Education/Support Groups (patients/families)	1	2	3	4
v.	Other Enhanced Services that Address Psychosocial Problems Concomitant with the OUD (Specify)	1	2	3	4

CON’T

35.

For the Opioid STR funding period between May 1, 2018 and April 30, 2019, identify the opioid use disorder treatment and/or recovery services that your community/program: (1) has not implemented; (2) implemented prior to the grant and expanded or enhanced using non-Opioid-STR funding; (3) implemented using Opioid STR funding; or (4) implemented prior to the grant and expanded or enhanced using Opioid STR funding. Where possible, estimate the number of new cases (i.e., individuals who had not previously received service) you served with these services using Opioid STR funding between May 1, 2018 and April 30, 2019.

			MARK ONE FOR EACH ROW
		NOT IMPLEMENTED	EXPANDED/ ENHANCED USING NON-OPIOID STR FUNDING	IMPLEMENTED USING OPIOID STR FUNDING	EXPANDED/ ENHANCED USING OPIOID STR FUNDING	# NEW CASES
w.	Wrap-Around Services (If possible, provide additional information about wrap-around services below in rows x through cc)	1	2	3	4
x.	Child Care	1	2	3	4
y.	Employment Services	1	2	3	4
z.	Housing	1	2	3	4
aa.	Individual Services Coordination	1	2	3	4
bb.	Transportation	1	2	3	4
cc.	Other (specify)	1	2	3	4
INFRASTRUCTURE
dd.	Health Information Technology Systems	1	2	3	4
ee.	Data Extraction for Real Time Reporting	1	2	3	4
ff.	Secured Physical Space (e.g., purchased building)	1	2	3	4
gg.	Opioid-Specific Practitioner Trainings	1	2	3	4
OTHER
hh.	Other (specify)	1	2	3	4

CON’T

36.

In the table below, indicate the population(s) that your community/program targeted for your Opioid STR prevention strategies, treatment, and/or recovery services between May 1, 2018 and April 30, 2019. For example, if you targeted all pregnant women for a treatment intervention, you would select “Females”; you would not have to select all the possible race/ethnicity categories that might be pregnant. If, however, you targeted African American and Hispanic pregnant women, then you would select “Hispanic/Latinos” and “African Americans” as well.

(These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.)

		MARK ONE OR MORE FOR EACH ROW
Check if you targeted this population for		Prevention	Treatment	Recovery
a.	A specific population has not been identified to target for Opioid STR activities	1	2	3
b.	Males	1	2	3
c.	Females	1	2	3
d.	Hispanics/Latinos (Including those from Central America, Cuba, Dominican Republic, Mexico, Puerto Rico, and South American countries)	1	2	3
e.	African Americans	1	2	3
f.	Asians (Including those from Southeast Asia, China, the Philippines, Japan, Korea, Vietnam, and other Asian countries)	1	2	3
g.	Native Hawaiians or other Pacific Islanders	1	2	3
h.	Alaska Natives	1	2	3
i.	American Indians	1	2	3
j.	Caucasians	1	2	3
k.	Children (aged <12)	1	2	3
l.	Adolescents (12-17)	1	2	3
m.	Transitional Age Youth (18-25)	1	2	3
n.	Adults (26-64)	1	2	3
o.	Adults (aged 65+)	1	2	3
p.	Parents/caregivers	1	2	3

CON’T

36.

In the table below, indicate the population(s) that your community/program targeted for your Opioid STR prevention strategies, treatment, and/or recovery services between May 1, 2018 and April 30, 2019. For example, if you targeted all pregnant women for a treatment intervention, you would select “Females”; you would not have to select all the possible race/ethnicity categories that might be pregnant. If, however, you targeted African American and Hispanic pregnant women, then you would select “Hispanic/Latinos” and “African Americans” as well.

(These categories are not mutually exclusive. Use your judgment to select all responses that describe your target population.)

		MARK ONE OR MORE FOR EACH ROW
Check if you targeted this population for		Prevention	Treatment	Recovery
q.	Physicians/health care providers/prescribers	1	2	3
r.	Pharmacists/dispensers	1	2	3
s.	Current or former military or military families	1	2	3
t.	Lesbian/gay/bisexual/transgender/questioning (LGBTQ)	1	2	3
u.	People living in poverty	1	2	3
v.	People whose primary language is other than English (or who are have limited English proficiency (LEP))	1	2	3
w.	People with mental illness	1	2	3
x.	People with disabilities (e.g., hearing, visually, or physically impaired)	1	2	3
y.	People who are reentering the community	1	2	3
z.	Homeless	1	2	3
aa.	People living with HIV/AIDS	1	2	3
bb.	Injection Drug Users	1	2	3
cc.	Other target population (Specify)	1	2	3
dd.	Other target population (Specify)	1	2	3
ee.	Other target population (Specify)	1	2	3
ff.	Other target population (Specify)	1	2	3
gg.	Will target all populations for Opioid STR activities	1	2	3

37.

Which of the following community or communities did you target for your Opioid STR treatment and/or recovery services between May 1, 2018 and April 30, 2019? SELECT ALL THAT APPLY
1	Large urban area (population of more than 500,000)
2	Smaller urban area (population of 50,000 to 500,000)
3	Small town or urban cluster (population or 2,500 to 49,999)
4	Rural
5	Entire state
6	Other (Specify)

38.

Which of the following community or communities did you target for your Opioid STR prevention strategies between May 1, 2018 and April 30, 2019? SELECT ALL THAT APPLY
1	Large urban area (population of more than 500,000)
2	Smaller urban area (population of 50,000 to 500,000)
3	Small town or urban cluster (population or 2,500 to 49,999)
4	Rural
5	Entire state
6	Other (Specify)

39.

How has your community/program increased access to opioid use disorder prevention strategies, treatment, and/or recovery services using Opioid STR funding for underserved populations (which may include racial/ethnic minority populations, individuals who are difficult to engage in services, or other populations in your state) between May 1, 2018 and April 30, 2019? SELECT ALL THAT APPLY
1	Completed a Disparities Impact Statement
2	Identified high-needs/low capacity communities
3	Identified populations that experience health disparities
4	Requested training/technical assistance (T/TA) about delivering services or strategies to high-needs communities
5	Received training/technical assistance (T/TA) about delivering services or strategies to high-needs communities
6	Requested training/technical assistance (T/TA) about delivering services or strategies to populations that experience health disparities
7	Received training/technical assistance (T/TA) about delivering services or strategies to populations that experience health disparities
8	Monitored and/or evaluated approaches used to address health disparities populations
9	Measured outcomes of health disparities populations
10	Other (Specify)

Sustainability

Sustain

This section focuses on how your community/program is implementing efforts to sustain systems, processes, or approaches to address opioid use disorder.

40.

Which of the following activities did your community/program start or conduct to sustain current efforts to address opioid use disorder between May 1, 2018 and April 30, 2019? SELECT ALL THAT APPLY
1	Diversifying funding streams
2	Fostering community involvement and ownership
3	Creating partnerships
4	Institutionalizing policies
5	Building a data infrastructure
6	Developing a training plan
7	Participating in sustainability training
8	Building public awareness
9	Seeking additional Federal funds
10	Developing a sustainability action plan
11	Establishing data monitoring to assess sustainability in an ongoing way
12	Evaluating progress to improve and adapt programs over time
13	Obtaining differential reimbursement rates for use of evidence-based practices
14	Other (specify)
11	Sustainability has not been addressed

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Opioid State Targeted Response (STR) Evaluation COMMUNITY PROGRAM DIRECTOR
Subject	SAQ
Author	MATHEMATICA
File Modified	0000-00-00
File Created	2021-01-22