0391 HR _Nonsubstantive Change_CLEAN

Harm Reduction Grant Annual Data

(TARGET SETTING FORM COMPLETED ANNUALLY)

Grantee Information

1. Organization Name: ____________________ 2. Grant Number: __________________

3. Federal Fiscal Year (circle one): 2023 2024 2025 2026

PLEASE ENTER THE EXPECTED TOTAL AMOUNT FOR EACH ITEM BELOW.

1. Service Encounter Target Setting (To be completed on an annual basis.)

1. Total number of service encounters expected this year (In the field): __ __ __ __

2. Total number of service encounters expected this year (At a facility): __ __ __ __

2. Commodities Purchased Target Setting (To be completed on an annual basis.)

1. Total number of safe sex kit supplies expected to be purchased: __ __ __ __

2. Total number of naloxone kits (nasal spray) expected to be purchased (1 kit=2 doses): __ __ __ __

3. Total number of naloxone kits (intramuscular) expected to be purchased (1 kit=2 doses): __ __ __ __

4. Total number of vending machines expected to be purchased/leased: __ __ __ __

5. Total amount of stock for vending machines expected to be purchased: __ __ __ __

6. Total number of medication lock boxes expected to be purchased: __ __ __ __

7. Total number of sharps/medication disposal boxes expected to be purchased: __ __ __ __

8. Total number of wound care management supplies expected to be purchased: __ __ __ __

9. Total number of fentanyl test strips expected to be purchased: __ __ __ __

10. Total number of other substance test strips expected to be purchased: __ __ __ __

11. Total number of sterile syringes expected to be purchased: __ __ __ __

12. Total number of safe smoking kits expected to be purchased: __ __ __ __

3. Specific Harm Reduction Service Encounters Target Setting (To be completed on an annual basis.)

Overdose Prevention
Expected number of naloxone trainings to be provided: __ __ __ __
Expected number of individuals to receive naloxone trainings: __ __ __ __ Expected number of overdose education sessions to be provided: __ __ __ __ Expected number of individuals to receive overdose education trainings: __ __ __ __
Expected number of other overdose prevention services to be provided: __ __ __ __
Expected number of individuals to receive other overdose prevention services: __ __ __ __

2. Mental and Physical Health Promotion

   1. Expected number of counseling services to be provided: __ __ __ __

   2. Expected number health education sessions to be provided: __ __ __ __

   3. Expected number of other mental/physical/health promotion services to be provided: __ __ __ __

3. Linkages to Treatment and Recovery Support Services

   1. Expected number of linkages to peer services: __ __ __ __

   2. Expected number of linkages to treatment services: __ __ __ __

   3. Expected number of linkages to recovery services: __ __ __ __

   4. Expected number of other linkages to treatment and recovery support services: __ __ __ __

4. Demographics (Please enter the estimated number of encounters for each category.)

1. Gender (by encounters)

1. Female: __ __ __ __

2. Male: __ __ __ __

3. Transgender: __ __ __ __

4. Non-Binary: __ __ __ __

5. Other: __ __ __ __

2. Ethnicity (by encounters)

1. Hispanic, Latino/a, or Spanish Origin: __ __ __ __

2. Not Hispanic, Latino/a, or Spanish Origin: __ __ __ __

3. Race (by encounters)

1. American Indian or Alaskan Native: __ __ __ __

2. Asian: __ __ __ __

3. Black or African American: __ __ __ __

4. Native Hawaiian or Other Pacific Islander: __ __ __ __

5. White: __ __ __ __

6. Multiracial: __ __ __ __

4. Age (by encounters)

1. Under 15 years __ __ __ __

2. 15 to 17 years __ __ __ __

3. 18 to 24 years __ __ __ __

4. 25 to 34 years __ __ __ __

5. 35 to 44 years __ __ __ __

6. 45 to 54 years __ __ __ __

7. 55 to 64 years __ __ __ __

8. 65 years and older __ __ __ __

Harm Reduction Grant Quarterly Data

PERFORMANCE REPORT

Grantee Information

1. Organization Name: ___________________________ 2. Grant Number: ________________

3. Federal Fiscal Year (circle one): 2023 2024 2025 2026

4. Federal Fiscal Quarter (Circle One): 1 2 3 4

PLEASE ENTER THE QUARTERLY TOTAL AMOUNT FOR EACH ITEM BELOW.

1. Encounters Attained Actual

Report Quarterly

Total Number of Service Encounters (Field)

Total Number of Service Encounters (Facility)

2. Commodities Purchased/Distributed

Safe Sex Kit Supplies Purchased
Safe Sex it Supplies Distributed
Naloxone Kits Purchased (nasal spray) (1 kit=2 doses)
Naloxone Kit Distributed (nasal spray) (1 kit=2 doses)
Naloxone Kits Purchased (intramuscular) (1 kit=2 doses)
Naloxone Kits Distributed (intramuscular) (1 kit=2 doses)
Vending Machines Purchased/Leased
Stock for Vending Machines Purchased
Medication Lock Boxes Purchased
Medication Lock Boxes Distributed
Sharps/Medication Disposal Boxes Purchased
Sharps/Medication Disposal Boxes Distributed
Wound Care Management Supplies Purchased
Wound Care Management Service Encounters
Fentanyl Test Strips Purchased
Fentanyl Test Strips Distributed
Other Substance Test Strips Purchased

Other Substance Test Strips Distributed
Sterile Syringes Purchased
Sterile Syringes Distributed
Smoking Kits Purchased
Smoking Kits Distributed

3. Specific Harm Reduction Service Encounters

1. Infectious Disease Prevention and Support Services

HIV Testing
VH Testing
VH Vaccination Services

Other Infectious Disease Prevention and Treatment
Other Safer Drug Services

2. Overdose Prevention

Naloxone Trainings
Individuals Receiving Naloxone Training
Overdose Education Sessions
Individuals Receiving Overdose Education Sessions
Other Overdose Prevention Services
Individuals Receiving Other Overdose Prevention Services

3. Mental and Physical Health Promotion

Counseling Services
Health Education Sessions
Other Mental and Physical Health Promotion Services

4. Linkages to Treatment and Recovery Support Services

Linkages to Peer Services
Linkages to Treatment Services
Linkages to Recovery Services

Other Linkages to Treatment and Recovery Support Services

PREP Linkages
HIV Treatment Linkages
VH Treatment Linkages

4. Demographics (Please enter the actual number of encounters for each category.)

1. Gender (by encounters)

1. Female __ __ __ __

2. Male __ __ __ __

3. Transgender __ __ __ __

4. Non-Binary __ __ __ __

5. Other __ __ __ __

6. Unknown/Not Provided __ __ __ __

2. Ethnicity (by encounters)

1. Hispanic, Latino/a, or Spanish Origin __ __ __ __

2. Not Hispanic, Latino/a, or Spanish Origin __ __ __ __

3. Unknown/Not Provided __ __ __ __

3. Race (by encounters):

1. American Indian or Alaskan Native __ __ __ __

2. Asian __ __ __ __

3. Black or African American __ __ __ __

4. Native Hawaiian or Other Pacific Islander __ __ __ __

5. White __ __ __ __

6. Multiracial __ __ __ __

7. Unknown/Not Provided __ __ __ __

4. Age (by encounters):

1. Under 15 years __ __ __ __

2. 15 to 17 years __ __ __ __

3. 18 to 24 years __ __ __ __

4. 25 to 34 years __ __ __ __

5. 35 to 44 years __ __ __ __

6. 45 to 54 years __ __ __ __

7. 55 to 64 years __ __ __ __

8. 65 years and older __ __ __ __

9. Unknown/Not Provided __ __ __ __

5. QUARTERLY PROGRAM PROGRESS NARRATIVE

Please use this section to describe activities, challenges, successes, and innovations that have occurred during this reporting period.

1. Overall progress: (1-2 paragraphs. Please share an update on the program progress completed during this reporting period related to overall programmatic implementation and to approved goals and objectives).

2. Challenges/Barriers: (1-2 paragraphs. If applicable, please share program challenges faced during this reporting period related to overall programmatic implementation and to approved goals and objectives and identified strategies to overcome them).

3. Successes: (1-2 paragraphs. If applicable, please share program accomplishments achieved during this reporting period related to overall programmatic implementation and to approved goals and objectives).

4. Innovations: (1-2 paragraphs. If applicable, please share program innovations developed and/or implemented during this reporting period related to harm reduction initiatives).

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