Annual Reporting T Annual Reporting Tool

Strategic Prevention Framework for Prescription Drugs (SPF Rx)

Attachment 1_SPF-Rx Annual Reporting Tool 05.31.2022CLEAN - 13July 22

OMB: 0930-0377

Document [docx]
Download: docx | pdf

ATTACHMENT 1

Annual Reporting Tool (ART) – Strategic Prevention Framework for Prescription Drugs (SPF Rx)

Program Evaluation for Prevention (PEPC) – Cross-Site Evaluation




OMB No. 0930-0377

Expiration Date 02/29/2024


Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of the Strategic Prevention Framework for Prescription Drugs (SPF Rx) grant program. This information collection will be used at an aggregate level to assess implementation of Strategic Prevention Framework steps, including related barriers and the reach of the SPF Rx interventions. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0377. Public reporting burden for this collection of information is estimated to average 4 hours per response, 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 Ln, Room 15 E57B, Rockville, MD 20857.



Timing of Instrument Items:

  • E = Every time (annually)

  • B = Baseline only

  • F = Final only




Contents

Information and Directions 1

Purpose 1

Requirements 1

Organization of the Survey 1

Inclusion of Key Informants 2

Helpful Materials 2

Entering and Saving Data 2

Survey Assistance 2

Definition of Terms 3

Section 1: Administrative Survey 5

Organization Type (Subrecipients only) 5

Funding History (Subrecipients only) 6

Section 2: Strategic Prevention Framework 7

Section 2A. Needs, Population of Focus, and Resources Assessments 7

Needs Assessment (Subrecipients only) 7

Data Sources (Subrecipients only) 7

Barriers (Subrecipients only) 10

Targeted Populations and Outcomes (Both grantees and subrecipients) 12

Section 2B. Capacity Building and Sustainability (Subrecipients only) 16

Current Capacity (Subrecipients only) 16

Training and Technical Assistance (Subrecipients only) 17

Development of SPF Rx Organizational Resources (Subrecipients only) 18

Relationship Building (Subrecipients only) 19

PDMP Data Access (Subrecipients only) 22

Barriers (Subrecipients only) 23

Sustainability (Subrecipients only) 24

Section 2C. Prevention Intervention Implementation (Both grantees and subrecipients complete) 26

Implemented Prevention Interventions 27

Prevention Intervention and Service Type Information 29

Intervention questions 29

Community-Based Processes Sub-Form 33

Overall Population of Focus reached by this intervention-service type 35

Prevention Education Sub-Form 37

Overall Population of Focus served by this intervention-service type 38

Alternative Drug-Free Activities Sub-Form 40

Overall Population of Focus served by this intervention-service type 41

Problem Identification and Referral Sub-Form 44

Overall Population of Focus served by this intervention-service type 45

Environmental Strategies Sub-Form 47

I. Training and educating environmental influencers 47

II. Policy, regulation, or law enactment or implementation 49

III. Enforcement implementation 55

IV. Safe Storage and Disposal Strategies 55

V. Other Environmental Strategies 56

Overall Population of Focus reached by this intervention-service type 56

Information Dissemination Sub-Form 59

Overall Population of Focus reached by this intervention-service type 65

Barriers 67

Section 2D. Monitoring and Evaluation (Subrecipients only) 69

Barriers 70

Section 3: Broad Contextual Factors (Both grantees and subrecipients complete) 72

Section 4: Closing Questions (Both grantees and subrecipients complete) 74


Information and Directions

Purpose

The Annual Reporting Tool (ART) collects data annually from primary SPF Rx grantees and their subrecipient communities about SPF Rx implementation, including:

  • Subrecipient communities’ progress through the Strategic Prevention Framework (SPF); and

  • The specific prevention interventions being implemented by subrecipient communities and primary grantees.

For SPF Rx, interventions may be implemented by primary grantees as well as their community subrecipients. Subrecipient communities will complete the whole survey, while primary grantees will mainly report on prevention interventions that they implement. Data collected from the survey will be used to monitor subrecipient and state, tribal entity, or jurisdiction performance and evaluate the effectiveness of the Strategic Prevention Framework for Prescription Drugs (SPF Rx) program across states, tribal entities, and jurisdictions. The overall goal of the cross-site evaluation is to document and assess the effectiveness of the SPF Rx approach to SAMHSA’s mission of reducing prescription drug misuse.

Requirements

Completion of this survey is a requirement of accepting funding from CSAP through your state, tribal entity, or jurisdiction under the SPF Rx grant initiative.

Organization of the Survey

Make sure to read all of the directions and examples. Primary grantees and subrecipient communities will complete this form once for each Federal fiscal year (annually). To minimize respondent burden and decrease completion time, this web-based survey allows information entered in previous reporting periods to be prefilled where possible and uses skip patterns to take you automatically to the appropriate question on the basis of your responses.

You will need to complete separate forms related to implementation information for each set of prevention intervention activities implemented. For example, if your community/jurisdiction implements both a participant-based education prevention intervention and an environmental prevention intervention, you will complete implementation information for both of those interventions. Similarly, if your community implements two different participant-based prevention education intervention strategies, you will complete implementation information for both of those interventions.

Information provided in this instrument focuses on communities, so no individuals will be identified in the reporting of results.

Throughout this instrument, the term “you” refers to the primary SPF Rx grantee (state/tribal entity/jurisdiction) or the subrecipient community that has received SPF Rx funding from the state/tribal entity/jurisdiction. The SPF Rx subrecipient community could be an organization, coalition, or other entity.

Inclusion of Key Informants

You are strongly encouraged to obtain input from others involved with the SPF Rx-funded project at the grantee and/or subrecipient level. As part of this process, we encourage you to print out a hard copy of the instrument and review it with key individuals, as appropriate and relevant for your SPF Rx grant.

People you may want to include in responding to this survey (if these positions are applicable to your grant)

  • Project Director

  • Project Coordinator

  • Person with responsibility or knowledge of financial issues

  • State or Tribal Epidemiology and Outcomes Workgroup (SEOW) Liaison

  • Data Coordinator

  • Local Evaluator

  • Intervention delivery staff

  • Coalition representatives

  • Key stakeholders or partners

Helpful Materials

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

  • budgets;

  • results of needs and resources assessments;

  • strategic plans;

  • meeting minutes;

  • memoranda of understanding;

  • prevention intervention implementation materials (curricula, programs, etc.);

  • evaluation findings and reports; and

  • organizational policies.

Entering and Saving Data

As you enter your data, you will be able to save your work and come back to it at another time. We recommend that you write your responses to the open-ended questions requiring narrative information in advance using a word processor and copy and paste them into the web-based survey.

Survey Assistance

If you need assistance in using the web-based data entry system, contact the Help Desk by leaving a message at 866-245-8079 or by email at pepc@rti.org. You can request assistance at any time, and someone will respond to you within 24 hours or the next business day.

Definition of Terms

The following are definitions for several terms used throughout this instrument. Links to the definitions list can also be found on each page of the web-based survey.

  • Capacity refers to the quality and/or level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF Rx, capacity refers to the demonstrated ability of subrecipients to implement each SPF step effectively (e.g., implementation of evidence-based interventions) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model.

  • Capacity building refers to activities conducted to improve the ability of an organization or community to deliver prescription drug misuse prevention services, such as improving organizational resources; improving awareness about prescription drug misuse problems; building new relationships or strengthening existing relationships among coalitions, groups, and organizations involved in prescription drug misuse prevention; and working to ensure that prevention intervention activities and outcomes continue after funding ends.

  • Community refers to the politically or geographically defined area or culturally or epidemiologically defined population of focus that the subrecipient chooses for each prevention intervention.

  • Community needs and resources assessments examine needs and resources external to the organization and include community readiness (definition below), rates of prescription drug and opioid misuse, prevention resources (e.g., call centers, trained implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.

  • Community readiness is the community's level of awareness of, interest in, and ability and willingness to support prescription drug misuse prevention initiatives. More broadly, it connotes readiness for changes in community knowledge, attitudes, motives, policies, and actions.

  • Consequences are defined as the social, economic, and health problems associated with misuse of prescription drugs—for example, overdoses and deaths related to prescription drugs.

  • Consumption patterns are the ways in which people misuse prescription drugs.

  • Directly served refers to individual-based prevention strategies or services directly delivered to individuals, either on a one-on-one basis or in a group format. Typically, the service provider and the participant are at the same location during the service encounter, but these activities may also take place virtually. Examples include training sessions and educational classes.

  • Environmental strategies are efforts to establish or change community standards, codes, and attitudes and thus reduce the incidence and prevalence of prescription drug misuse. Approaches can center on legal and regulatory issues or can relate to service and action-oriented initiatives. Examples include technical assistance (TA) to communities to increase health care provider’s use of prescription drug monitoring program data when prescribing opioid pain medication.

  • Federal fiscal year goes from October 1 through September 30 of the following year.

  • Indirectly reached describes population-based prevention strategies aimed at impacting an entire population. Since there is no direct interaction between the populations impacted by the services, counts of people reached are typically estimates obtained from sources such as the Census or media outlets. Common indirect strategies include information dissemination and environmental strategies.

  • Intervening variables are risk or protective factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of prescription drug misuse and related risk behaviors and their consequences. These variables are the focus of prevention interventions, changes in which are then expected to affect consumption and consequences.

  • In-kind resources include labor that supports the SPF Rx grant at subsidized or no cost to the grant or other resources donated to the SPF Rx grant, such as equipment, supplies, or office space.

  • Interventions are funded activities carried out under the auspices of the SPF Rx grant. They target a variety of subpopulations with the objective of improving outcomes related to prescription drug and opioid misuse.

  • Key stakeholders are all the members of the community who have a vested interest (a stake) in the activities or outcomes of the SPF Rx prevention intervention.

  • Leveraging resources is the process of combining SPF Rx-funded resources with other resources to augment prevention intervention delivery (i.e., to do more together than with SPF Rx resources alone). For example, subrecipients combine SPF Rx funding with funding from another source [e.g., Comprehensive Addiction and Recovery Act (CARA) or CDC Overdose to Action grants) to augment the implementation of their SPF Rx intervention. In many instances, leveraging functions through collaborative relationships.

  • Participants are the recipients of the SPF Rx prevention interventions.

  • Primary grantee or grantee refers to the administrative entity (such as the state, tribal entity, or jurisdiction) receiving SPF Rx funds for delivery of prescription drug misuse prevention interventions.

  • Social marketing uses the principles of commercial marketing to develop, implement, and evaluate interventions designed to influence the behavior of a target audience.

  • Subrecipients are the entities (usually community-based organizations, schools, or coalitions) that receive funds from the grantee and carry out SPF Rx activities or prevention interventions.

  • Sustainability is the process through which a prevention system becomes a norm and is integrated into ongoing operations. Sustainability is vital to ensuring that prevention values and processes are firmly established, that partnerships are strengthened, and that financial and other resources are secured over the long term.

Section 1: Administrative Survey

[GRANTEES SKIP TO QUESTION 8 AND COMPLETE TARGETED POPULATIONS AND OUTCOMES SUBSECTION]

This section asks questions that describe your subrecipient organization. Your subrecipient organization should be identified as the entity that is carrying out the activities/interventions of the SPF Rx program.

Organization Type (Subrecipients only)

Subrecipient Name (System prefill) (locked)

________________________________________________________________________________

1. What type of organization would you say your subrecipient organization is? You should identify your organization as the entity that will be carrying out the activities of the SPF Rx program. (Select the one response that best describes your organization.) B

  • Community coalition (If selected, you will skip Question 2.)

  • Local public health/mental health government agency responsible for substance use prevention

  • Local health/mental health care service provider or facility (e.g., local hospital, community mental health center)

  • Youth-focused local grassroots or community-based service or advocacy organization (e.g., local chapter of Students Against Destructive Decisions [SADD], local youth councils)

  • Non-youth-focused, local grassroots or community-based service or advocacy organization (e.g., substance use prevention organizations)

  • Faith-based organization

  • School or school district

  • Law enforcement organization

  • College or university

  • Tribal entity or organization

  • Other government agency, not listed above (Describe.) __________________________

  • Other nonprofit organization, not listed above (Describe.) _________________________

  • Other (Describe.)

2. Are you partnering with a community coalition (an existing group that brings together diverse organizations and individuals to collaborate on shared prevention goals) on your SPF Rx activities? By partnering, we mean that you have a formal relationship that is documented with a memorandum of understanding or similar agreement and/or that you provide SPF Rx funding to support activities of the coalition. (Select one response.) B, F

  • Yes

  • No

Funding History (Subrecipients only)

3. Has your subrecipient organization (i.e., entity that will be leading the activities of the SPF Rx) received Strategic Prevention Framework Partnerships for Success (SPF PFS) funding? (Select one response.)B

  • Yes (If selected, you will skip Question 4.)

  • No

  • Don’t know

4. Has your subrecipient organization (i.e., entity that will be leading the activities of the SPF Rx) been part of a coalition or group or organizations that received SPF PFS funding in the past? (Select one response.)B

  • Yes

  • No

  • Don’t know


Section 2: Strategic Prevention Framework

This section asks for information related to the Strategic Prevention Framework steps. You will be asked to describe your activities related to the following steps:

  • needs, population of focus, and resources assessments;

  • capacity building and sustainability;

  • prevention intervention implementation; and

  • monitoring and evaluation.

Section 2A. Needs, Population of Focus, and Resources Assessments

[GRANTEES SKIP TO QUESTION 8, POPULATION OF FOCUS AND OUTCOMES]

This section collects information on organizational and community needs and resources assessments you conducted during this reporting period. First, you are asked whether or not the needs and resources of your community have been assessed. In this section, please also describe any data you have available and the data you used to conduct your needs and resources assessment. This section also asks about the consumption patterns, consequences, intervening variables, and populations you identified to target for your SPF Rx activities.

Needs Assessment (Subrecipients only)

5. Has your organization completed an assessment of community needs and resources during the past Federal fiscal year? A community needs and resources assessment examines needs external to the organization and includes rates of substance use and related consequences (e.g., overdose), as well as community readiness, prevention resources (e.g., trained intervention implementers), partnerships, community prevention experience, and other monetary and nonmonetary resources.E

  • Yes

  • No (If selected, skip Questions 6 and 7 on data sources and barriers to needs assessments.)

Data Sources (Subrecipients only)

This set of questions asks about the availability of community-level prescription drug-related data for data-driven planning (e.g., needs assessments, identifying priority issues and intervening variables to target, performance monitoring). We want you to focus on local-level data that are available for your target community or communities.

6. For each of the types of data listed below, check the boxes to indicate (a) whether or not you have access to the data for your target communities (or closest available substate area), and (b) whether you used the data to conduct your community needs and resources assessment. Do NOT check “Yes” if the data are only available at the state level.E (autofill once completed initially)

Data Type

Have access to community-level data

The data were used for needs assessment

Yes

No

Yes

No

Consumption

6.1. Prescription drug misuse in the past 30 days or past year

6.2. Prescription pain reliever misuse in the past 30 days or past year

6.3. Lifetime prescription drug misuse (ever misused)

6.4. Lifetime prescription pain reliever misuse (ever misused)

6.5. Other (Describe.) _____________________________

Consequences

6.6. Mortality rates due to opioid overdose

6.7. Emergency department visits/hospital admissions related to opioid misuse/overdose

6.8. Calls to poison control center related to opioid misuse

6.9. Other (Describe.) _________________________

Intervening Variables

6.10. Rate of registration of physicians with prescription drug monitoring program (PDMP)

6.11. Use of PDMP by physicians (number of queries; percentage of physicians making queries)

6.12. Rate of opioid prescribing

6.13. Rate of high-dose opioid prescribing (e.g., > 90MME/day or > 100MME/day)

6.14. Rate of opioid and benzodiazepine co-prescribing

6.15. Rate of multiple prescriber episodes for opioid pain medication (as indicator of possible “doctor shopping”)

6.16. Rate of multiple pharmacy episodes for opioid pain medication

6.17. Other PDMP measure of opioid prescribing (Describe.) _______________________________

6.18. Consumers’ perceived risk of prescription drug misuse

6.19. Parent/peer attitudes about prescription drug misuse

6.20. Communication with parents about drug use

6.21. Social availability (e.g., through friends or family members)

6.22. Physicians’ attitudes and knowledge

6.23. Law enforcement practices (e.g., to address diversion; having police use Narcan to prevent overdose)

6.24. Other (Describe.) _____________________________


Needs Assessment Barriers (Subrecipients only)

In this section, we would like to learn about barriers and challenges that had an impact on assessing the needs, population of focus, and resources in your community, state, tribal area, or jurisdiction during this reporting period.

7. How much did the following factors impact the progress or results of your SPF Rx efforts related to conducting an assessment of community needs and resources in the past Federal fiscal year?

Note: If a specific item is not yet applicable or you do not know the answer based on your stage of implementation, you should check “No impact.”


Factors Impacting Needs Assessment E

No impact

Low impact

Moderate impact

High impact

  1. Inadequate training/technical assistance to assess community needs and resources

  1. Difficulty staffing assessment activities (e.g., delays in hiring, delays in training, turnover)

  1. Limited time for staff and team members to devote to assessment activities

  1. Too broad a geographic area across which to assess needs and resources

  1. Not enough grant funds to support assessment activities

  1. Limited ability to leverage other funds or in-kind donations to support assessment activities

  1. Difficulty coordinating or collaborating with our grantee organization (state/tribe/jurisdiction)

  1. Difficulty coordinating or collaborating with other (non-grantee) public health and substance use agencies and coalitions

  1. Difficulty accessing data on outcomes and consequences (e.g., PDMP data, hospital overdose data)

  1. Difficulty obtaining data specific to disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Difficulty obtaining data specific to high-need subpopulations (e.g., based on age, residential area, socioeconomic status [SES], or other factors)

  1. Mismatch between level of disaggregation of available data (e.g., at state level) and level of project implementation (e.g., in counties within state)

  1. Difficulty analyzing data on outcomes and consequences (e.g., PDMP data, hospital overdose data)

  1. Poor quality of data on outcomes and consequences (e.g., PDMP data, hospital overdose data)

  1. Difficulty engaging health care providers and pharmacists

  1. Difficulty engaging disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Difficulty engaging high-need subpopulations (e.g., based on age, residential area, SES)

  1. Stressful events affecting large portions of the community (e.g., natural disasters, COVID-19 related closures, other unexpected traumatic events) (Describe.) ___________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________




Targeted Populations and Outcomes (Both grantees and subrecipients)

This set of questions asks about the specific populations and outcomes your community, state, tribal entity, or jurisdiction has identified for your SPF Rx efforts. (Note: Grantees should report their overall targets for their state, jurisdiction, or tribal area) Complete at baseline and update annually if you have any changes.

8. Indicate the consumption pattern(s) you are targeting for your SPF Rx activities. (Select all that apply.)E (autofill once completed initially)

  • Have not identified a consumption pattern to target

  • Misuse of any prescription drugs

  • Misuse of prescription pain relievers

  • Misuse of prescription stimulants

  • Misuse of prescription benzodiazepines

  • Other consumption pattern (Describe.)

9. Indicate the consequence(s) you are targeting for your SPF Rx activities. (Select all that apply.)E (autofill once completed initially)

  • Have not identified a consequence to target

  • Emergency department visits or hospitalizations related to prescription drug overdose

  • Emergency department visits or hospitalizations related to opioid overdose

  • Poison control center calls related to prescription drug overdose

  • Poison control center calls related to opioid overdose

  • Prescription drug-related overdose deaths

  • Opioid-related overdose deaths

  • Motor vehicle crashes related to prescription drug or opioid misuse

  • Crime related to prescription drug or opioid misuse

  • Other consequences (Describe.)

10. Indicate the population(s) you will be focusing on for your SPF Rx prevention activities. In the first column, we would like to know if you have very specific groups of people you are focusing on for your prevention interventions. For example, if you are delivering a prevention intervention to all middle schools in an area, then you would select only “middle school students”; you would not have to select all the possible race/ethnicity categories that might be enrolled in the schools. If, however, you are delivering a prevention intervention specifically designed to target high school-aged Latinos, then you would select Hispanic and high school students. (Note: If you are targeting the whole community or jurisdiction, then choose that answer option [10.1], and do not check all the subpopulations.) (These categories are not mutually exclusive. Use your judgment to select all responses that describe your population of focus.)E (autofill once completed initially)

In the second column, check any specific subpopulation your SPF Rx prevention activities are focused on to reduce prescription drug misuse-related behavioral health disparities. According to Healthy People 2030, “Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” We are asking you to specify which of the population(s) you are targeting for your SPR-Rx activities because they experience disparities within your community or communities.

Population

Check if you are specifically focusing on this subpopulation

Check if this subpopulation represents your behavioral health disparities population of focus

10.1. We are targeting community-wide or statewide population, not any specific subpopulations

N/A

10.2. Males

10.3. Females

10.4. LGBTQ

10.5. African Americans

10.6. American Indians

10.7. Alaska Natives

10.8. Asian/Pacific Islanders

10.9. Hispanics

10.10. Whites

10.11. Ages 12–17

10.12. Ages 18–25

10.13. Ages 26 and over

10.14. Other age group (Specify Describe.) ___________________

10.15. Middle school students

10.16. High school students

10.17. College students

10.18. Parents

N/A

10.19. Current or former military or military families

10.20. Individuals living in poverty

10.21. Individuals whose native language is other than English

10.22. Individuals with low literacy

10.23. Individuals with mental illness

10.24. Individuals with disabilities (e.g., hearing, visually, or physically impaired)

10.25. Physicians/health care providers/prescribers

N/A

10.26. Pharmacists/dispensers

N/A

10.27. Other population of focus (Specify.) _______________________________________

10.28. Other population of focus (Specify.) _______________________________________

10.29. Other population of focus (Specify.) _______________________________________



11. Indicate the intervening variable(s) you will be targeting for SPF Rx prevention. (Select all that apply.)E (autofill once completed initially)

  • Have not yet selected an intervening variable to target

  • Laws or regulations related to prescription drug monitoring program (PDMP) data (access, use, timeliness, or quality)

  • Laws or policies related to prescriber or dispenser training or practices

  • Other laws or policies related to prescription drugs/pain medications

  • Law enforcement practices (e.g., to address diversion, having police use Narcan to treat suspected overdose)

  • Social access to prescription drugs (e.g., through friends or family members)

  • Physician attitudes and knowledge about safe prescribing practices

  • Physician/prescriber registration with prescription drug monitoring program

  • Physician/prescriber use of prescription drug monitoring program (number of queries; percentage of physicians making queries)

  • Rate of opioid prescribing

  • Rate of high-dose (> 90 MME/day) opioid prescribing

  • Rate of opioid and benzodiazepine co-prescribing

  • Rate of multiple prescriber episodes for opioid pain medications (or other indicators of possible “doctor shopping”)

  • Rate of multiple pharmacy episodes for opioid pain medication

  • Norms—perceived parent or peer attitudes or both (toward prescription drug misuse)

  • Norms—perceived peer or friend misuse of prescription drugs

  • Consumers’ perceived risk of harm of prescription drug misuse

  • Consumers’ perceived risk of getting caught misusing prescription drugs

  • Family communication around prescription drug misuse

  • Resistance or life skills or both

  • Availability of prosocial activities

  • Other intervening variable (Describe.)

  • Other intervening variable (Describe.)

  • Other intervening variable (Describe.)

12. How would you describe the community or communities that you are targeting for your SPF Rx prescription drug misuse prevention activities? (Select all that apply.)E (autofill once completed initially)

  • Entire state/jurisdiction

  • Large urban area(s) (population of more than 500,000)

  • Smaller urban area(s) (population of 50,001 to 500,000)

  • Small town or urban cluster(s) (population of 2,500 to 50,000)

  • Rural area(s)

  • Other (Describe.)


[GRANTEES SKIP TO SECTION 2C PREVENTION INTERVENTION IMPLEMENTATION]

Section 2B. Capacity Building and Sustainability (Subrecipients only)

In this section, we ask you about your activities related to capacity and sustainability. Capacity refers to the quality and level of skills (e.g., workforce) and resources needed to achieve a desired outcome. For SPF Rx, capacity refers to the demonstrated ability of subrecipients to effectively implement each SPF step (i.e., assess needs, build capacity, plan, implement, and evaluate) and the resources (human, organizational, and fiscal) to support the implementation of the SPF model. Capacity building refers to activities conducted to improve the ability of an organization or community to deliver prescription drug misuse prevention services, such as improving organizational resources, seeking and receiving relevant training and technical assistance (T/TA), building new relationships or strengthening existing relationships among groups and organizations involved in prescription drug misuse prevention, and ensuring that prevention intervention activities and outcomes continue after SPF Rx funding ends.

Current Capacity (Subrecipients only)

13. How much would you agree or disagree that your organization currently has enough capacity in each of the following areas to effectively implement your SPF Rx prevention efforts? (Note: At baseline, the questions should be answered with regard to your organization’s capacity at the time you received SPF Rx funds.) E

Capacity Areas

Strongly disagree

Disagree

Agree

Strongly agree

13.1. Capability and experience using the 5 SPF steps

13.2. Experience with the populations of focus for prescription drug misuse prevention

13.3. Experience working with health care providers and pharmacists for prescription drug misuse prevention

13.4. Experience with relevant interventions for prevention of prescription drug misuse

13.5. Experience collaborating with other organizations on interventions to prevent prescription drug misuse

13.6. Capability to use prescription drug monitoring program (PDMP) data for prevention planning, surveillance, and evaluation

13.7. Staff with the right skills to effectively implement SPF Rx prevention efforts

13.8. Enough staff to effectively implement SPF Rx prevention efforts

13.9. Enough fiscal/financial resources to effectively implement SPF Rx prevention efforts

13.10. Capability to sustain the prevention efforts over time

13.11. Experience addressing behavioral health disparities in prevention efforts

Training and Technical Assistance (Subrecipients only)

14. Select the area(s) in which your organization or staff needed and/or received SPF Rx-related guidance or training and technical assistance (T/TA) during the past Federal fiscal year. We are specifically asking about guidance and T/TA that contributed to your SPF Rx activities. (Select all that apply.) E

  • We did not need or receive any guidance or T/TA that contributed to SPF Rx activities

Training/technical assistance (T/TA) areas

Needed or need T/TA in this area during the past Federal fiscal year

Received T/TA in this area during the past Federal fiscal year

14.1. Assessing community needs and resources

14.2. Using prescription drug monitoring program (PDMP) data for prevention surveillance, planning, or evaluation

14.3. Using other data sources for prevention assessment, planning, and evaluation

14.4. Understanding opioid misuse and epidemiology, including risk and protective factors

14.5. Developing a strategic plan for substance use prevention

14.6. Building collaborative relationships with stakeholders and partner agencies



14.7. Working with medical and pharmaceutical communities to prevent prescription drug misuse

14.8. Developing strategies to enhance PDMP use

14.9. Identifying and selecting prescription drug misuse interventions

14.10. Recruiting intervention participants

14.11. Adapting interventions for prescription drug misuse

14.12. Delivering culturally competent interventions

14.13. Addressing behavioral health disparities

14.14. Evaluating interventions for prescription drug misuse

14.15. Sustaining interventions for prescription drug misuse

14.16. Conducting social marketing/social media/public education

14.17. Leveraging strategies to increase safe storage and disposal of prescription drugs

14.18. Working with law enforcement to prevent prescription drug misuse

14.19. Engaging in public policymaking (e.g., collaborating to inform or implement policy change)

14.20. Other (Describe.) __________________________________

14.21. Other (Describe.) __________________________________

14.22. Other (Describe.) __________________________________


Development of SPF Rx Organizational Resources (Subrecipients only)

This section collects information on the activities you conducted to improve your SPF Rx organizational capacity and which funding resources you had available for SPF Rx activities.

15. Other than training and obtaining technical assistance TA, have you conducted activities that produced gains in your SPF Rx organizational resources or capabilities related to SPF Rx during the past Federal fiscal year? These could include such activities as recruiting community partners and improving staff and funding. (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 16.)

16. Besides training and obtaining TA, indicate the activity or activities you conducted during the past Federal fiscal year that produced gains in your SPF Rx organizational resources. (Select all that apply.)E

  • Created an advisory board

  • Recruited new community partners

  • Increased staffing

  • Secured additional funding

  • Secured physical space

  • Modified or developed data infrastructure (for prescription drug prevention efforts)

  • Other: (Describe.)

17. Below is a list of funding sources that could be used to support prevention of prescription drug misuse. Please indicate whether your organization has used funding from this source to support SPF Rx–related activities during the past Federal fiscal year. Consult with your SPF Rx grantee if you are unsure of some of these funding sources. Do not include funding received by other organizations in your coalition or group, unless those funds are used for SPF Rx–related activities.E



  • We did not use other sources of funding to support SPF Rx related activities during the past Federal fiscal year

Source of funding/resources

Used funding from this source to support SPF Rx–related activities during the past Federal Fiscal year

YES

NO

17.1. SAMHSA Strategic Prevention Framework Partnerships for Success (SPF PFS)

17.2. SAMHSA Substance Abuse Prevention and Treatment Block Grant

17.3. SAMHSA Grants to Prevent Prescription Drug/Opioid Overdose-Related Deaths (PDO)

17.4. SAMHSA Medication-Assisted Treatment-Prescription Drug and Opioid Addiction (MAT-PDOA)

17.5. SAMHSA State Targeted Response to the Opioid Crisis Grants (Opioid STR)

17.6. SAMHSA Comprehensive Addiction and Recovery Act (CARA) Local Drug Crises Grants

17.7. SAMHSA First Responders-Comprehensive Addiction and Recovery Act (FR-CARA)

17.8. SAMHSA Harm Reduction Program Grant

17.9. SAMHSA HIV Capacity Building Initiative (HIV CBI)

17.10. SAMHSA Substance Abuse and HIV Prevention Navigator Program for Racial/Ethnic Minorities

17.11. SAMHSA Sober Truth on Preventing (STOP) Underage Drinking

17.12. CDC Overdose Data to Action (OD2A)

17.13. Bureau of Justice Assistance (BJA) Harold Rogers Prescription Drug Monitoring Program (PDMP)

17.14. HRSA Rural Opioid Overdose Reversal (ROOR)

17.15. Drug-Free Communities (DFC) grant

17.16. Medicaid (Federal, state, local)

17.17. Other Federal funds (Describe.) _______________________________________

17.18. Other state/tribal/jurisdiction funds (Describe.) _______________________________________

17.19. Other local government funds (Describe.) _______________________________________

17.20. Foundations/nonprofit organizations

17.21. Corporate/business entities

17.22. Individual donations/funding from fundraising events

17.23. Other (Describe.) _______________________________________

Relationship Building (Subrecipients only)

This section collects information on partners you identified to join in planning or delivering your SPF Rx prevention intervention activities.

18. Have you identified key stakeholders, partners, or partner organizations to participate in your SPF Rx planning and prevention intervention activities? This includes coalition members if you are working with a coalition. (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 19.)

19. Provide more information on the key stakeholders, partners, and partner organizations that participate in your organization’s SPF Rx activities. This may include a combination of individuals and organizations. “Active” refers to stakeholders/partners who demonstrated support or participation in your activities and interventions during the past Federal fiscal year.E (autofill column 2 after initially completed)

  • We did not have any key stakeholders, partners, or partner organizations participate in our SPF Rx related activities during the past Federal fiscal year



Sector

For each sector below, how many of these key stakeholder or partner members were “active” during the past Federal Fiscal year?

What was the average level of involvement for the members of this sector in your SPF Rx activities during the past Federal Fiscal year?

(Mark only if # active partners >0)

Low

Medium

High

19.1. Physicians/health care providers or health care organizations (excluding hospitals/hospital staff)


19.2. Hospital medical staff or hospital organization


19.3. Dentists or dental organizations


19.4. Pharmacists/pharmacy organizations


19.5. Substance use prevention professionals/organizations


19.6. Substance use treatment professionals/organizations


19.7. Mental health professionals/agencies


19.8. Insurance professionals or organizations


19.9. Youth groups/representatives


19.10. Schools/school districts


19.11. Colleges and universities


19.12. Other youth-serving professionals/organizations


19.13. Parents/family/caregiver groups


19.14. Tribal leaders or elders


19.15. Business community


19.16. Workers compensation programs


19.17. Media (radio/TV stations; newspapers)


19.18. Clergy/faith-based organizations


19.19. Civic or volunteer organizations/professionals


19.20. Organizations/individuals serving LGBTQ population


19.21. Military professionals/agencies


19.22. Law enforcement professionals/agencies


19.23. Courts/judiciary system professionals/agencies


19.24. Other state, local, or tribal government agencies (Describe.) _____________


19.25. Other organizations/sectors (Describe.) _____________


19.26. Other organizations/sectors (Describe.) _____________


19.27. Other organizations/sectors (Describe.) _____________




PDMP Data Access (Subrecipients only)

20. Did your community have access to community-level prescription drug monitoring program (PDMP) data/reports for prevention planning prior to the SPF Rx 2021 grant?B

  • Yes, we had access to community-level PDMP data but did not normally use it for prevention planning.

  • Yes, we had access to and normally used community-level PDMP data for prevention planning.

  • No, we did not have access to community-level PDMP data.

21. During the past Federal fiscal year, approximately how often did you receive or access updated PDMP data/reports for your SPF Rx target communities (or the closest available substate area)? (Select one)E

  • We did not receive or access any PDMP data/reports in the past fiscal year

  • Once

  • Semi-annually (twice per year)

  • Quarterly

  • Every other month

  • Monthly

  • Other (Specify.)

22. For what geographic area are PDMP data/reports available to you? (Select all that apply.)E (update annually only if it changes)

  • PDMP data are not available to us yet

  • Community

  • County

  • District or Region

  • State

  • Other (Specify.) _________________________________________________________

23. Are privacy or HIPAA concerns a major barrier to receiving community-level PDMP reports?E (update annually only if it changes)

  • Yes

  • No



24. How has your access to and use of community-level PDMP data/reports as part of your SPF Rx effort affected your local prevention efforts? (Select all that apply.) F

  • We did not get access to any community-level PDMP data/reports during the grant

  • We had access to community-level PDMP data/reports, but we were not able to use them

  • PDMP data did not significantly change our prevention approach

  • PDMP data changed our understanding of the problem

  • PDMP data guided local prevention strategies in new directions

  • PDMP data enabled us to better monitor risky prescribing and dispensing patterns

  • PDMP data informed enforcement efforts in new ways

  • Other (Describe.)

Capacity Building Barriers (Subrecipients only)

In this section, we would like to learn about barriers and challenges that had an impact on building capacity in your community, state, tribal area, or jurisdiction during this reporting period.

25. How much did the following factors impact the progress or results of your SPF Rx efforts related to improving the ability of your organization or community to deliver prescription drug misuse prevention services in the past Federal fiscal year? E

Note: If a specific item is not yet applicable or you do not know the answer based on your stage of implementation, you should check the box “No impact.”



Factors Impacting Capacity Building

No impact

Low impact

Moderate impact

High impact

  1. Inadequate training/technical assistance to build capacity

  1. Difficulty staffing capacity-building activities (e.g., delays in hiring, delays in training, turnover)

  1. Limited time for staff and team members to devote to capacity building

  1. Building capacity across too broad a geographic area

  1. Not enough grant funds to support capacity-building activities

  1. Limited ability to leverage other funds or in-kind donations to support capacity-building activities

  1. Difficulty coordinating or collaborating between grantee organization and subrecipients

  1. Difficulty coordinating or collaborating with other (non-grantee) public health and substance use agencies and coalitions

  1. Public health and substance abuse agencies and coalitions prioritize prescription drug/opioid misuse treatment over prevention

  1. Lack of prioritization of prescription drug/opioid misuse prevention by state leadership (e.g., governor's office, legislature)

  1. Difficulty getting buy-in and support from the medical community (e.g., health care professionals, medical or pharmacy boards and associations)

  1. Difficulty engaging health care providers and pharmacists

  1. Difficulty engaging disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Difficulty engaging high-need subpopulations (e.g., based on age, residential area, SES)

  1. Stressful events affecting large portions of the community (e.g., natural disasters, COVID-19 related closures, other unexpected traumatic events) (Describe.) _________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________



Sustainability (Subrecipients only)

This section asks about things you have done to ensure that SPF Rx–related prevention intervention activities and outcomes continue once SPF Rx funding ends. These efforts might focus on ensuring continued funding, structures, networks, partnerships, leadership, and resources.

26. During the past Federal fiscal year, how have you worked to ensure that prescription drug misuse prevention intervention activities and outcomes continue after SPF Rx funding has ended? (Select all that apply.)E

  • Have not done work in the past year to ensure that prescription drug misuse prevention intervention activities and outcomes continue after SPF Rx funding has ended

  • Leveraged, redirected, or realigned other funding sources or in-kind resources to carry on SPF Rx efforts

  • Obtained new funding (e.g., used the success of the SPF Rx efforts to secure other funds)

  • Worked to ensure that prescription drug misuse prevention intervention activities are incorporated into the missions/goals and activities of other organizations (e.g., medical boards, local pharmacies, school districts, law enforcement agency)

  • Worked to ensure that prescription drug misuse prevention staff positions are integrated into other organizations (e.g., health departments, school districts, community agencies)

  • Worked to gain formal adoption of prescription drug misuse prevention intervention activities into other organizations’ practices (e.g., health care provider organizations, pharmacies, medical school curriculum, school district curriculum, organizational policy change)

  • Worked to inform, help implement, or provide education related to new laws, policies, or regulations to guarantee the continuation of prescription drug misuse prevention intervention activities or outcomes

  • Worked on developing a prescription drug misuse partnership structure that will continue to function beyond the end of the SPF Rx grant period

  • Worked to create sustainable data infrastructure and staffing to continue to monitor PDMP and other surveillance data after SPF Rx grant ends

  • Other (Describe.)



Section 2C. Prevention Intervention Implementation (Both grantees and subrecipients complete)

This section collects information about the SPF Rx prevention interventions you selected for implementation in your service area. A prevention intervention is an activity or set of activities to which a group or community is exposed to in order to change their behavior. For SPF Rx, these activities should aim to prevent or lower the rate of prescription drug misuse and related problems. Interventions include activities related to:

  • Community-based processes (e.g., holding meetings or training with community members, reallocating funds to prevention activities in the community, reorganizing local agencies and organizations to address prevention of prescription drug misuse)

  • Prevention education (e.g., mentoring, school-based youth education programs, parenting programs)

  • Alternative activities (e.g., free social and recreational events, events at community drop-in centers or youth centers),

  • Problem identification and referral (e.g., student screening and referral)

  • Environmental strategies (e.g., training of environmental influencers, policy change, enforcement)

  • Information dissemination and other communication activities (e.g., conducting media campaigns, distribution of materials at health fairs)

Refer to the Annual Reporting Tool (ART) manual for more information on prevention interventions.

27. Did you or your community partners deliver any SPF Rx–related prevention interventions during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 28–146.)

Implemented Prevention Interventions

28. Name all the prevention interventions you or your partners delivered during this reporting period as part of your SPF Rx efforts. Refer to the Annual Reporting Tool (ART) Manual before you complete this section. That document will help you understand what to report as a prevention intervention; which activities you should list as separate service types related to that intervention; and how to determine the appropriate CSAP strategy type, Institute of Medicine category, and so on.E (autofill for interventions previously reported, except for active/inactive status)



You will need to complete a separate implementation information sub-form for each prevention intervention-service type you name below that was active during the past Federal fiscal year. The CSAP strategy type will determine a subset of questions you must complete for the prevention intervention and service type.

28a. Intervention name

28b. Service type

28c. Service type name

28d. Date started

28e. CSAP strategy type

28f. Institute of Medicine (IOM) category

28g. Status

28h. Date completed or discontinued

From the drop-down menu, select the name of each prevention intervention you are implementing, or select “other” and write in the name. To review a full list of the intervention names, refer to the Intervention Name List.

From the drop-down menu, select the service type for each major set of services or activities you are implementing under this prevention intervention, or select “other” and write in the name. Many strategies may consist of only one service type.

Write in the name of the specific set of services or activities that you implemented as part of your intervention if this name differs from the service type label.

Date you began funding this intervention-service type through your SPF Rx initiative

(MM/YYYY)

Select the CSAP strategy type that best describes this intervention-service type:

  • Community-based processes

  • Environmental strategy

  • Prevention education (of the public)

  • Alternative activities

  • Problem identification and referral

  • Environmental strategy

  • Information dissemination (and other communication activities)

Select the IOM category for this intervention-service type:

  • Universal direct

  • Universal indirect

  • Selective

  • Indicated

Check whether the intervention-service type was Active, Inactive, Completed, or Discontinued during the past Federal fiscal year.

For intervention-service types completed or discontinued during the past year, indicate the date completed or discontinued (MM/YYYY).




Sample Table:

28a. Intervention name

28b. Service type

28c. Service type name

28d. Date started

28e. CSAP strategy type

28f. Institute of Medicine (IOM) category

28g. Status

28h. Date completed or discontinued

Train/educate health care providers on safe prescribing/CDC guidelines

Training/ educating environmental influencers

Training/ educating environmental influencers

03/2022

Environmental

Universal indirect

Completed

09/2023

Media campaign—Count it! Lock it! Drop it!

Media campaigns

Media campaigns

05/2022

Information dissemination

Universal direct

Active


Policy, reg, or law change/ implementation—prescriber opioid training

Change/ implement new public policies, regs, or laws

Change/ implement new public policies, regs, or laws

10/2022

Environmental

Universal indirect

Completed


12/2023

Prescription Drug Safe Storage and/or Disposal—Drop Box Installation

Prescription drug safe storage and/or disposal


Prescription drug safe storage and/or disposal

01/2022

Environmental

Universal indirect

Completed

01/2023


Prevention Intervention and Service Type Information

Questions in this section are only asked for each intervention active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________E (autofill from Question 26)

Intervention questions

29. What specific consumption pattern(s) or consequence(s) (or both) are the prevention intervention intended to target? (Select all that apply.)E (autofill after first completed)

  • Misuse of any prescription drugs

  • Misuse of prescription pain relievers

  • Misuse of prescription stimulants

  • Misuse of prescription benzodiazepines

  • Prescription drug/opioid-related deaths

  • Emergency department visits or hospitalizations related to prescription drug/opioid overdose

  • Poisoning center calls related to prescription drug/opioid overdoses

  • Motor vehicle crashes related to prescription drug/opioid misuse

  • Crime related to prescription drug/opioid misuse

  • Other consumption pattern (Describe.)

  • Other consequence (Describe.)

30. What specific intervening variable(s) is the prevention intervention intended to target? (Select all that apply.)E (autofill after first completed)

  • This intervention is not targeting a specific intervening variable

  • Laws or regulations related to prescription drug monitoring program (PDMP) data (access, use, timeliness, or quality)

  • Laws or policies related to prescriber or dispenser training or practices

  • Other laws or policies related to prescription drugs/pain medications

  • Law enforcement practices (e.g., to address diversion, having police use Narcan to treat suspected overdose)

  • Social access to prescription drugs (e.g., through family and friends)

  • Physicians’ attitudes and knowledge about safe prescribing practices

  • Physician/prescriber registration with PDMP

  • Physician/prescriber use of PDMP (number of queries; percentage of physicians making queries)

  • Rate of opioid prescribing

  • Rates of high-dose opioid prescribing (> 90MME/day)

  • Rate of opioid and benzodiazepine co-prescribing

  • Rates of multiple prescriber episodes for opioid pain relievers (as indicator of possible “doctor shopping”)

  • Rates of multiple pharmacy episodes for opioid pain medication

  • Norms—perceived parent or peer attitudes or both (toward prescription drug misuse)

  • Norms—perceived friend or peer misuse of prescription drugs

  • Consumers’ perceived risk of harm of prescription drug misuse

  • Consumers’ perceived risk of getting caught misusing prescription drugs

  • Family communication around prescription drug misuse

  • Resistance or life skills or both

  • Availability of prosocial activities

  • Other intervening variable (Describe.)

  • Other intervening variable (Describe.)

  • Other intervening variable (Describe.)

31. To your knowledge, is this intervention an evidence-based program, policy, or practice (EBPPP)? EBPPPs are defined as interventions that come from a Federal Registry, were reported as effective for your target substance in a published scientific journal article, were based on a documented theory of change, or were deemed effective by a panel of experts (Select one response.)E (autofill after first completed)

  • Yes

  • No

  • Don’t know

32. How did you select your intervention? (Select all that apply.)E (autofill after first completed)

  • Inclusion in a Federal registry of evidence-based interventions

  • Found to be effective (on the primary targeted outcome) in a published, scientific journal

  • Similar in content and structure to interventions that appear in registries or peer-reviewed literature

  • Supported by documentation of effective implementation multiple times in the past (showing consistent pattern of positive effects)

  • Reviewed by a panel of informed experts including qualified prevention researchers, local prevention practitioners, and key community leaders (e.g., law enforcement and education representatives, elders within indigenous cultures)

  • Recommended by evidence-based practice workgroup (EPBW)

  • Appeared on a list of recommended promising or evidence-based programs, policies, and practices provided by our state, tribal entity, or jurisdiction

  • Recommended by the SPF Rx grantee (state, tribe, or jurisdiction) but not on a formal list of promising or evidence-based programs, policies, and practices

  • Is based on guidelines, protocols, standards, or preferred practice patterns that have been proven to lead to effective prevention outcomes

  • Based on a theory of change that is documented in a clear logic or conceptual model

  • Other (Describe.)

33. Have you renamed the existing promising or evidence-based program, policy, or practice to implement it in your community? (Select one response.) E (autofill after first completed)

  • Yes (Provide the original name.)

  • No


34. Which of the following best describes the implementation history of this prevention intervention in your community? (Select one response.)E (autofill after first completed)

  • Not implemented in the community before SPF Rx 2021 funding

  • Continuation of a PFS or SPF Rx 2016 prevention intervention

  • Continuation of a non-PFS or non-SPF Rx 2016 prevention intervention

35. Were any adaptations made to address the cultural appropriateness of the prevention intervention for a particular group (e.g., modifying the language or slang used, modifying the examples, including visuals of individuals who represent your population of focus) in the past Federal fiscal year? (Select one response.)E

  • Yes (Describe the adaptations.)

  • No

36. Did you collaborate with any organizations or individuals to implement this intervention for SPF Rx in the past Federal fiscal year? E

  • Yes

  • No

  • Don’t know



Service type questions

Questions in this section are only asked for each intervention active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________ (autofill from Question 26)

Service Type: ___________________________________________ (autofill from Question 26)

37. For Questions 37.1–37.5, indicate the locations and population of focus being served by this prevention intervention-service type. If you are implementing in separate settings (e.g., schools, workplaces), list each setting separately. (Note: If you are implementing a media campaign that reaches the whole county, you may enter “countywide” for location [Question 37.1].)

Use one line to describe each location served by the intervention-service type. Other than estimated population of focus (Question 37.5), you need to complete only those categories that are appropriate for this prevention intervention-service type and community served.E (autofill after first completed)


37.1. Location (e.g., school name, business, community center)

37.2. City/town

37.3. County/ parish

37.4. Population of focus description (Describe; 500-character limit)

37.5. What is the estimated number of individuals within your population of focus within the location listed?a

1.






2.






3.






4.






5.






6.






7.






8.






9.






10.






a The number of individuals within your population of focus is likely smaller than the total population in the location. For example, if 10,000 individuals live in the area (total population), but only 3,000 of those are in the target 12- to 20-year-old age group for this prevention intervention, your estimated target population is 3,000. If your target population for this prevention intervention is more specific (e.g., Hispanic high school students or non-college youth aged 18 to 20), your population of focus number would be even smaller (e.g., 200). Report your population of focus size as accurately as possible.

Community-Based Processes Sub-Form

Questions in this section are only asked for each intervention categorized as a community-based process (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________ E (autofill from Question 28)

Service Type: ___________________________________________ E (autofill from Question 28)

For this sub-form, we are interested in community-based intervention-service type activities that you expect will enhance the ability of the community or prevention system to influence substance use. Community-based processes you describe here might include holding more specific meetings with or training key stakeholders and partners or other community members and organizations; developing prevention provider networks; reorganizing local agencies; reallocating community prevention funds; or formally changing how local organizations work together to prevent substance misuse.

Activities related to more general capacity building (e.g., training prevention staff, building stakeholder or partner relationships) or the general functioning of your organization (e.g., coalition meetings) should not be included here and are better described in the capacity-building section earlier in this instrument. Also, you should categorize trainings of environmental influencers such as physicians/pharmacists as environmental strategies for CSAP strategy type and complete that sub-form instead.

38. For this intervention-service type, did you do any work related to community-based processes (e.g., stakeholder/partner meetings, T/TA for community, reorganization of local agencies, or reallocation of community funds for prescription misuse prevention) during the past Federal Fiscal year? E

  • Yes

  • No (If selected, you will automatically proceed to the end of this sub-form.)

39. Indicate the number of stakeholder/partner meetings you held during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E

meetings (If none, enter “0.”)

40. Indicate the number of stakeholders/partners you trained during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E

stakeholders/partners trained (If none, enter “0.”)

41. Indicate the number of community members, other than stakeholders/partners, you trained during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E

community members trained (If none, enter “0.”)

42. Indicate the number of community organizations to whom you provided training or technical assistance during the past Federal fiscal year for this intervention-service type, if any. This response should be written as a whole number (e.g., 4).E

community organizations (If none, enter “0.”)

43. Did you develop a prescription drug misuse prevention provider network during the past Federal fiscal year for this intervention-service type? For example, you may have established a prescriber and dispenser group that meets regularly. (Select one response.)E

  • Yes

  • No, we do not yet have a network

  • No, a network was already in place

44. For this intervention-service type, during the past Federal fiscal year, did you help with reorganizing agencies to promote efficiency in delivering prescription drug misuse prevention services? (Select one response.)E

  • Yes

  • No

45. For this intervention-service type, during the past Federal fiscal year, did you reallocate other (non-SPF Rx) sources of funding to help support the goals of your SPF Rx effort? (Select one response.)E

  • Yes

  • No

46. For this intervention-service type, during the past Federal fiscal year, did you formally change the ways organizations work together to prevent prescription drug misuse —for example, by documenting specific policies or practices for working together? (Select one response.)E

  • Yes

  • No

47. For this intervention-service type, did you conduct other community activities during the past Federal fiscal year? (Select one response.)E

  • Yes (Describe.)

  • No



Overall Population of Focus reached by this intervention-service type

48. Estimate the total number of individuals in your population of focus who were indirectly reached or affected by this community-based process intervention-service type during the past Federal fiscal year. Approximately how many individuals were affected by the results of this intervention-service type? (Note: Because this is a population-based intervention, you are asked to estimate the number of people reached. In most cases, this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E

(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)

Enter the estimated number of individuals in the population of focus indirectly reached or affected by your implementation of this community-based process intervention type x during the past Federal fiscal year. (If none, enter “0.”) _____________________

(If none, enter “0”—you will automatically proceed to the end of this sub-form.)

49. Of the total number of participants served by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total reported in Question 48. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E

49.1. Females: _____________

49.2. Males: ______________

49.3. Transgender: ______________

49.4. Other: (Describe .)_________________ (Specify: _____________________)

49.5. Gender unknown: ______________

50. Of the total number of participants served by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 48. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

50.1. Children aged 0 to 11: _____________

50.2. Youth aged 12 to 17: _____________

50.3. Young adults aged 18 to 25: _____________

50.4. Adults aged 26 and older: _____________

50.5. Age unknown: ___________

51. Of the total number of participants served by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 48. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

51.1. American Indian or Alaska Native: _____________

51.2. Black or African American: _____________

51.3. White: _____________

51.4. Asian: _____________

51.5. Native Hawaiian or Other Pacific Islander: ______________

51.6. Multiracial: ___________

51.7. Other: _____________

51.8. Race unknown: ___________

52. Of the total number of participants served by this community-based process intervention during the past Federal fiscal year (reported in Question 48), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 48. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

52.1. Hispanic, Latino/a, or of Spanish origin: ____________

52.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

52.3. Hispanic ethnicity unknown: ____________

Prevention Education Sub-Form

Questions in this section are only asked for each intervention categorized as a prevention education intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________E (autofill from Question 28)

Service Type: ___________________________________________ E (autofill from Question 28)

This sub-form should focus on prevention education intervention-service types that involve two-way communication between an educator or facilitator and participants. Prevention education intervention-service type activities focus on improving critical life and social skills, such as decision-making, refusal, critical analysis of media messages, and judgment. These activities include classroom sessions for all ages, parenting and family management classes, and peer leader programs. Prevention education typically uses curriculum-based materials.

The activities included under prevention education should focus on more than just providing information to participants, such as through a community presentation or disseminating brochures or other materials; these types of one-way communication activities should be categorized as and described under information dissemination. Please categorize trainings of environmental influencers such as physicians/pharmacists as environmental strategies for CSAP strategy type in item 28 and complete that sub-form instead.

53. Indicate the type(s) of participants served by this prevention education intervention during the past Federal fiscal year (Select all that apply.)E

  • Middle school students

  • High school students

  • College students

  • Parents

  • Employees (i.e., recipients of a workplace substance misuse prevention program)

  • Current or former military members

  • Military family members

  • Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

  • Individuals living in poverty

  • Individuals whose native language is other than English

  • Individuals with low literacy

  • Individuals with mental illness

  • Individuals with disabilities (e.g., hearing, visually, or physically impaired)

  • Other (Describe.)

54. What was the average number of sessions provided for each group of participants in the prevention education intervention during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

___ sessions

55. What was the average length of the individual sessions, in hours, during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

___ hours

Overall Population of Focus served by this intervention-service type

56. How many total participants were served by this prevention education intervention during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

___ participants
(If none, enter “0”—you will automatically proceed to the end of this sub-form.)

57. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 56. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E

57.1. Females: _____________

57.2. Males: ______________

57.3. Transgender: ______________

57.4. Other: _____________________________ (Specify: _____________________)

57.5. Gender unknown: ______________

58. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 56. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

58.1. Children aged 0 to 11: _____________

58.2. Youth aged 12 to 17: _____________

58.3. Young adults aged 18 to 25: _____________

58.4. Adults aged 26 and older: _____________

58.5. Age unknown: ___________

59. Of the total number of participants served by this prevention education intervention during the past Federal fiscal year (reported in Question 56), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 56. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

59.1. American Indian or Alaska Native: _____________

59.2. Black or African American: _____________

59.3. White: _____________

59.4. Asian: _____________

59.5. Native Hawaiian or Other Pacific Islander: ______________

59.6. Multiracial: ___________

59.7. Other: _____________

59.8. Race unknown: ___________

60. Of the total number of participants served by this prevention education intervention during the past year (reported in Question 56), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 56. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

60.1. Hispanic, Latino/a, or of Spanish origin: ____________

60.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

60.3. Hispanic ethnicity unknown: ____________

Alternative Drug-Free Activities Sub-Form

Questions in this section are only asked for each intervention categorized as an alternative drug-free activity intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________E (autofill from Question 28)

Service Type: ___________________________________________ E (autofill from Question 28)

This sub-form should focus on alternative drug-free activities, including recognition and drug-free leisure activities implemented as a means of halting or reducing substance misuse. Alternative programs include a wide range of activities that appeal to children and youth: athletics, art, music, movies, and community service projects. Related intervention-service type activities often provide youth who live in high-risk communities with safe alternative environments and opportunities to develop relationships with non-substance-using peers.

61. Indicate the type(s) of participants served by this alternative drug-free activity strategy during the past Federal fiscal year. (Select all that apply.)E

  • Middle school students

  • High school students

  • College students

  • Parents

  • Employees (i.e., recipients of a workplace substance misuse prevention program)

  • Current or former military members

  • Military family members

  • Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

  • Individuals living in poverty

  • Individuals whose native language is other than English

  • Individuals with low literacy

  • Individuals with mental illness

  • Individuals with disabilities (e.g., hearing, visually, or physically impaired)

  • Other (Describe.)

62. Are the alternative activities targeted at identifiable participants (e.g., student clubs, mentoring) or with events for populations as a whole (e.g., drug-free events, festivals/fairs, drop-in activities)? (Select all that apply.)E

  • Identifiable participants (If selected, you will complete Questions 63-64.)

  • Populations as a whole (If selected, you will complete Questions 65-66.)

Questions for alternative activities targeted at identifiable participants

63. What was the average number of sessions provided for each group of participants in this alternative drug-free activity during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ session(s)

64. What was the total number of hours provided for each group of participants in this alternative drug-free activity during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ hour(s)

Questions for alternative activities delivered to populations as a whole, not identifiable participants

65. What type(s) of the alternative activity events that were not targeted to identifiable participants did you implement during the past Federal fiscal year? (Select all that apply.)E

  • Concert

  • Festival or fair

  • Sporting event

  • Picnic

  • Drop-in activity

  • Web-based gathering

  • Other (Describe.)

66. How many separate alternative activity events that were not targeted to identifiable participants were conducted during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ event(s)

Overall Population of Focus served by this intervention-service type

67. How many total participants were served by this set of alternative drug-free activities during the past Federal fiscal year? This response should be written as a whole number. Try to count each individual only once (e.g., 4). (Note: this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E

(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)

________ participants
(If none, enter “0”—you will automatically proceed to the end of this sub-form.)

68. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total number of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

68.1. Females: _____________

68.2. Males: ______________

68.3. Transgender: ____________________

68.4. Other (Describe.): ________________ (Specify: _______________________)

68.5. Gender unknown: _______________

69. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

69.1. Children aged 0 to 11: _____________

69.2. Youth aged 12 to 17: _____________

69.3. Young adults aged 18 to 25: _____________

69.4. Adults aged 26 and older: _____________

69.5. Age unknown: _____________



70. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

70.1. American Indian or Alaska Native: _____________

70.2. Black or African American: _____________

70.3. White: _____________

70.4. Asian: _____________

70.5. Native Hawaiian or Other Pacific Islander: ______________

70.6. Multiracial: ___________

70.7. Other: _____________

70.8. Race unknown: ___________

71. Of the total number of participants served by this set of alternative drug-free activities during the past Federal fiscal year (reported in Question 67), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 67. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

71.1. Hispanic, Latino/a, or of Spanish origin: ____________

71.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

71.3. Hispanic ethnicity unknown: ____________

Problem Identification and Referral Sub-Form

Questions in this section are only asked for each intervention categorized as a problem identification and referral intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________E (autofill from Question 28)

Service Type: ___________________________________________ E (autofill from Question 28)

This sub-form should focus on problem identification and referral activities that aim to identify those who have engaged in illegal or age-inappropriate use of alcohol, first use of illicit drugs, and nonmedical use of prescription drugs to reverse or stop the behavior. It may include screening programs to identify individuals in need of services, including online screening and feedback programs or employee and student assistance programs.

72. Indicate the type(s) of participants served by this Problem Identification and Referral prevention intervention during the past Federal fiscal year. (Select all that apply.)E

  • Middle school students

  • High school students

  • College students

  • Parents

  • Health care providers

  • Employees (i.e., recipients of a workplace substance misuse prevention program)

  • Current or former military members

  • Military family members

  • Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

  • Individuals living in poverty

  • Individuals whose native language is other than English

  • Individuals with low literacy

  • Individuals with mental illness

  • Individuals with disabilities (e.g., hearing, visually, or physically impaired)

  • Other (Describe.)

73. Where did this problem identification and referral activity take place during the past Federal fiscal year? (Select all that apply.)E

  • School

  • Health care facilities

  • Jails or prisons

  • Courts

  • Workplace or workplace program

  • Other (Describe.)

74. What type(s) of services were individuals referred to during the past Federal fiscal year? (Select all that apply.)E

  • Substance use treatment

  • Mental health treatment

  • Substance use prevention activities

  • Housing services

  • After-school activities

  • Transportation

  • Day care or adult care services

  • Health care

  • Other (Describe.)

Overall Population of Focus served by this intervention-service type

75. What was the total number of individuals served by the problem identification and referral services provided during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ individuals
”—.) (If none, enter “0”—you will automatically proceed to the end of this sub-form.)

76. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 75. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E

76.1. Females: _____________

76.2. Males: ______________

76.3. Transgender: ______________

76.4. Other (Describe.): __________________ (Specify: _____________________)

76.5. Gender unknown: ______________

77. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 75. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

77.1. Children aged 0 to 11: _____________

77.2. Youth aged 12 to 17: _____________

77.3. Young adults aged 18 to 25: _____________

77.4. Adults aged 26 and older: _____________

77.5. Age unknown: ___________

78. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 75. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

78.1. American Indian or Alaska Native: _____________

78.2. Black or African American: _____________

78.3. White: _____________

78.4. Asian: _____________

78.5. Native Hawaiian or Other Pacific Islander: ______________

78.6. Multiracial: ___________

78.7. Other: _____________

78.8. Race unknown: ___________

79. Of the total number of participants served by this problem identification and referral intervention during the past Federal fiscal year (reported in Question 75), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 75. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

79.1. Hispanic, Latino/a, or of Spanish origin: ____________

79.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

79.3. Hispanic ethnicity unknown: ____________

Environmental Strategies Sub-Form

Questions in this section are only asked for each intervention categorized as an environmental strategy intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________E (autofill from Question 28)

Service Type: ___________________________________________ E (autofill from Question 28)

This sub-form should focus on environmental strategies that establish or change community conditions to influence substance misuse. Approaches may center on policy, regulatory, or legal changes or implementation; efforts to maximize enforcement of laws or policies related to prescription drugs; organizational-level policy change; safe storage and disposal activities; or training of those able to directly influence environmental conditions, such as health care professionals, pharmacists, and law enforcement.

Note that you should report all media and communication campaigns as information dissemination and all parent education programs as prevention education for CSAP strategy type in item 28. Note that if you conduct an information dissemination campaign to promote use of existing prescription drug drop boxes, you would report that in the information dissemination sub-form. In this section, you would report on the installation of new drop boxes.

Throughout this section, refer to your organization or partners with your organization. For example, if you worked with the police department on diversion, you would report it on this form.

  1. Training and educating environmental influencers

In this section, report strategies that include providing training and individual education for those in positions to affect prescription drug misuse through policy, prescribing and dispensing practices, enforcement, communication, and so on (e.g., health care providers, pharmacists, law enforcement officers, school employees). Include only training and individual education related to the specific environmental strategy on which you are reporting in this sub-form. Do not include training conducted for other environmental strategies that you have listed as separate environmental strategies.

80. Did this environmental strategy include training or individual education (e.g., “detailing”) with environmental Influencers—those in positions to affect prescription drug misuse through policy, enforcement, communication, and so on (e.g., health care providers, pharmacists, law enforcement officers, school employees)—during the past Federal fiscal year? (Select all that apply.)E

  • Yes, group training of environmental influencers (If not selected, you will skip questions 82-83.)

  • Yes, individual one-on-one education of environmental influencers (If not selected, you will skip Question 84.)

  • No (If selected, you will skip Questions 81-85.)

81. To which types of environmental influencers did you provide training or individual education to affect prescription drug misuse through policy, enforcement, communication, and so on during the past Federal fiscal year? (Select all that apply.)E (autofill after first completed)

  • Health care providers/medical community

  • Dentists/dental community

  • Veterinarians/veterinary community

  • Pharmacists/pharmacy community

  • Insurers

  • School employees or administrators

  • Law enforcement

  • Other policymakers such as elected officials

  • Tribal leaders or elders

  • Business owners or employees

  • Service or civic organization employees or administrators

  • Media members

  • Military personnel or veterans’ organizations

  • Other (Describe.) ______________________________________________________

  • Other (Describe.) ______________________________________________________

  • Other (Describe.) ______________________________________________________

  • Other (Describe.) ______________________________________________________

82. How many training sessions were conducted for each group of environmental influencers during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ sessions

83. What was the average length of the group training sessions, in hours, during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ hours

84. What was the average length of time spent with individuals on one-on-one education of environmental influencers, in hours during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ hours

85. How many total individuals participated in group training or individual education of environmental influencers during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ individuals participated in group training of environmental influencers

________ individuals participated in individual education of environmental influencers

  1. Policy, regulation, or law enactment or implementation

In this section report on what you did through this SPF Rx environmental strategy related to policy, regulation, or law enactment or implementation at either the state level or with organizations at the local level. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities for other environmental strategies that you have listed as separate environmental strategies.

86. During the past Federal fiscal year, did your SPF Rx environmental strategy include any policy, regulation, or law enactment or implementation? This would include changing, implementing, or strengthening the implementation of new laws at the state level or working with organizations at the local level to develop or implement policies to advance the goals of SPF Rx (e.g., help health care provider organization institute policies to follow CDC guidelines for prescribing opioids). (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 87-93.)

87. During the past Federal fiscal year, did you do any work related to changing or implementing laws, regulations, government policies, or licensing requirements as part of your SPF Rx efforts? For example, this could involve state laws related to the use of PDMP data or to opioid prescribing practices.E

  • Yes

  • No (If selected, you will skip Questions 88-90.)



88. What types of activities were you engaged in during the past Federal fiscal year to support enactment or implementation of laws, regulations, governmental policies, or licensing requirements? (Select all that apply.)E

  • Met with elected officials or policymakers to educate them on the policy issues

  • Conducted research or analysis of policy options for officials or policymakers

  • Informed key stakeholders and institutions about the new policy, law, or requirement

  • Coordinated activities or meetings with key stakeholders and organizations

  • Developed informational materials (fliers, postcards, websites) related to the new policy, law, or requirement

  • Distributed informational materials (fliers, postcards, websites) related to the new law/policy/requirement

  • Other activities (Describe.)

  • Other activities (Describe.)

  • Other activities (Describe.)



89. Indicate which of the following laws, regulations, government policies, or licensing requirements you worked on during the past Federal fiscal year as part of your SPF Rx effort. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities that are part of other environmental strategies that you have listed as separate interventions. Note that some items will only be applicable to the primary grantee or the subrecipient, depending on whether they are state or local types of activities. For example, state-level grantees may be more involved in state-level legislative issues (e.g., prescription drug monitoring program [PDMP] laws) than subrecipient communities are.

Please check the boxes below for any specific laws, regulations, government policies, or licensing requirements that you worked on during the past year. Then indicate whether your activities related to change (enactment) or implementation of the new law, regulation, governmental policy, or licensing requirement (or both). (Select all that apply.)E

PDMP-related government policies, regulations, or laws at the state level:
  • Require universal prescriber registration with the PDMP

  • Involved with changing policy or law

  • Involved with implementation

  • Allow doctors to assign authorized delegates to access PDMP data

  • Involved with changing policy or law

  • Involved with implementation

  • Require participation in the PDMP for new types of prescribers (e.g., dentists, veterinarians)

  • Involved with changing policy or law

  • Involved with implementation

  • Have state rules that delineate circumstances when prescribers must query the PDMP for their patients’ history of opioid prescriptions

  • Involved with changing policy or law

  • Involved with implementation

  • Require that pharmacists upload opioid dispensing data more quickly (e.g., within 24 hours)

  • Involved with changing policy or law

  • Involved with implementation

  • Expand the scope of data reported to PDMP by pharmacists (e.g., source of payment)

  • Involved with changing policy or law

  • Involved with implementation

  • Allow expansion of PDMP data access to allow use for public health surveillance, prevention, and research

  • Involved with changing policy or law

  • Involved with implementation

  • Develop interstate agreements to share PDMP data (e.g., facilitate providers’ ability to query PDMPs of neighboring states)

  • Involved with developing policy

  • Involved with implementation of new policy

  • Create a linkage between patients’ PDMP records and their electronic health records

  • Involved with developing policy

  • Involved with implementation of new policy

PDMP-related data aggregation and reporting:
  • Change the algorithm by which patients with similar names and other characteristics are aggregated

  • Involved with developing policy

  • Involved with implementation of new policy

  • Produce regular reports from the PDMP that summarize key state, regional, or local statistics of interest

  • Involved with developing policy

  • Involved with implementation of new policy

  • Produce unsolicited reports from the PDMP

  • Involved with developing policy

  • Involved with implementation of new policy

For which group are the new unsolicited reports? (check all that apply):

  • Prescribers (Describe purpose.) ________________________________________

  • Dispensers (Describe purpose.) _________________________________________

  • Licensing boards (Describe purpose.) ____________________________________

  • Law enforcement agencies (Describe purpose.) ____________________________

  • Other group (Specify and describe purpose.) ______________________________

Prescribing-related government policies, regulations, or laws:
  • Mandate prescriber training on safe opioid prescribing

  • Involved with changing policy, regulation, or medical licensing board requirement

  • Involved with implementation of new requirement

  • Limit dose of opioid prescription (e.g., 90 MME/day) without special approval

  • Involved with changing state guidelines or state insurance/Medicaid pharmacy policy

  • Involved with implementation of new guidelines/policies

  • Limit duration of opioid prescription for chronic noncancer pain patients without special approval

  • Involved with changing state guidelines or state insurance pharmacy policies

  • Involved with implementation of new guidelines/policies

Pain clinic-related government policies, regulations, or laws:
  • Require pain clinics to be regularly certified by state medical board

  • Involved with changing law/regulations, policy, or medical board requirement

  • Involved with implementation of new requirement

  • Require pain clinics to be owned and operated by licensed physicians

  • Involved with changing law/regulations, policy, or medical board requirement

  • Involved with implementation of new requirement

Other changes to laws, regulations, or government policies
  • Other regulations, laws, or government policies related to SPF Rx that you worked on in the past year. (Describe. 3,000-character limit)

  • Involved with changing law/policy

  • Involved with implementation

90. Describe any new laws, regulations, licensing requirements, or government policies that were enacted, established, or implemented during the past Federal fiscal year related to this particular environmental strategy.E (3,000-character limit)

Organizational Policies

91. Did you work with individual organizations (e.g., local hospitals, local primary care organizations, pharmacies, insurers) during the past Federal fiscal year to help them to develop or implement organizational policies related to SPF Rx goals? E

  • Yes

  • No (If selected, you will skip Questions 92 and 93.)

92. Please check the boxes below to indicate any SPF Rx program activities you carried out during the past Federal fiscal year related to helping institutions develop or implement organizational policies. (Select all that apply.)E

PDMP data organizational policy
  • Worked with medical organizations to incorporate or implement policies to register health care providers/prescribers with the PDMP

  • Worked with medical organizations to incorporate or implement policies requiring their medical providers to query their patients’ PDMP records before prescribing opioids

  • Worked with pharmacy organizations to incorporate or implement policies to improve timeliness of PDMP upload

  • Worked with organizations to incorporate or implement policies to improve scope or quality of PDMP data

  • Worked with organizations to establish policies or agreements related to linkage of patient PDMP records with patient electronic health records (EHRs)

  • Worked with organizations to establish or implement policies or agreements related to linkage of PDMP data with vital records (deaths) or overdose data (e.g., emergency room visits or hospital admissions)

  • Worked with organizations to incorporate or implement policies to increase PDMP access or ease of use

Safe prescribing organizational policy
  • Helped institutions implement/incorporate national CDC (or similar state) prescribing guidelines into their rules and codes

  • Helped institutions incorporate alternatives to opioids for pain treatment

  • Helped medical or pharmacy schools to incorporate prescription drug/opioid misuse prevention-related education into their curricula

Pharmacy organizational policy
  • Helped organizations with pharmacy benefit strategy change (e.g., institute drug utilization reviews for high-dose opioids)

  • Helped pharmacies with policies related to querying PDMP for risky prescription patterns

Social access organizational policy
  • Helped with organizational policies related to social access, including safe storage and disposal of prescription drugs (e.g., help develop policies to facilitate broader distribution of home lock boxes to individuals filling prescriptions for opioids/controlled substances) (Describe.)

Development of enforcement organizational policy
  • Collaborated with organizations (e.g., medical regulatory bodies, law enforcement) to develop enforcement policies related to pain clinics

  • Collaborated with medical authorities (e.g., medical board/association) to develop policies to send letters to health care providers with higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP data

93. Describe any other work you did in the past Federal fiscal year related to helping individual organizations develop or implement policies that advance SPF Rx goals. (3,000-character limit).E _________________________________________________________________________

  1. Enforcement implementation

This section relates to the implementation of enforcement activities. (Development of new enforcement-related policies should be reported in the policy section.) Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate environmental strategies.

94. Did your environmental strategy include implementation of enforcement efforts (e.g., collaboration with law enforcement or medical/pharmaceutical authorities to respond to possible prescription drug diversion) during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 95 and 96.)

95. Indicate which of the following activities you worked to implement during the past Federal fiscal year related to enforcement (Select all that apply.).E

  • Collaborated with organizations (e.g., pharmacies, law enforcement) to prevent or respond to suspected diversion

  • Collaborated with organizations to enforce policies, laws, or regulations related to pain clinics

  • Collaborated with organizations to enforce policies or guidelines related to opioid prescribing

  • Collaborated with organizations to send letters or reports to health care providers with higher-than-usual opioid prescribing rates or risky prescribing behaviors based on PDMP data

  • Other major enforcement-related practices or activities in the past year (Describe; 3,000‑character limit.)

96. For this environmental strategy of enforcement, did you collaborate with law enforcement (e.g., work with law enforcement to familiarize them with high-risk areas of the community) during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No

  1. Safe Storage and Disposal Strategies

This section relates to the implementation of environmental strategies related to safe storage or disposal of prescription drugs. Include only activities related to the specific environmental strategy on which you are reporting in this sub-form. Do not include activities conducted for other environmental strategies that you have listed as separate environmental strategies

97. During the past Federal fiscal year, did you work on any environmental strategies related to safe storage or disposal of prescription drugs?E

  • Yes

  • No (If selected, you will skip Questions 98-101.)

98. How many prescription drop boxes were already in your target geographic area before you began your SPF Rx 2021 grant)? E (autofill after first completed) __________

99. During the past Federal fiscal year, how many prescription drug boxes did you install in law enforcement agencies, pharmacies, and other locations? Enter total for each type of location.E

_________ installed in law enforcement agencies

_________ installed in pharmacies

_________ installed other locations

100. How many prescription drug take-back events did you organize, support, or participate in during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E _________

101. During the past Federal fiscal year, did you engage in any other safe storage or disposal activities related to prescription drugs (e.g., increase the distribution or access to home lock boxes or Deterra bags)? E

  • Yes (Describe; 3,000-character limit.) ____________________________________

  • No

  1. Other Environmental Strategies

102. During the past Federal fiscal year, did you engage in any other environmental strategies that did not fall into the categories of safe storage/disposal, policy, enforcement, or training of environmental influencers? Describe any other environmental strategy you worked to or did implement during the past year.E

  • Yes (Describe; 3,000-character limit.)

  • No

Overall Population of Focus reached by this intervention-service type

The questions in this section collect information on the individuals ultimately reached or affected through your training of environmental influencers, enforcement efforts, policy-related activities, safe storage/disposal, or other environmental strategies. This goes beyond the number of individuals directly involved in the training, policy change, or enforcement to estimate the numbers affected in the targeted population in your entire community. This set of questions specifically refers to [NAME OF INTERVENTION-SERVICE TYPE ACTIVITY].

103. Estimate the total number of individuals who were reached or affected by your environmental strategy during the past Federal fiscal year. If you are unsure of the exact number of individuals affected, respond with your best estimate. This response should be written as a whole number (e.g., 4). (Note: this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E

(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)

_________ total individuals (If none, enter “0”—you will automatically proceed to the end of this sub-form.)



104. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 103. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E

104.1. Females: _____________

104.2. Males: ______________

104.3. Transgender: ______________

104.4. Other (Describe.): __________________ (Specify: _____________________)

104.5. Gender unknown: ______________

105. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 103. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

105.1. Children aged 0 to 11: _____________

105.2. Youth aged 12 to 17: _____________

105.3. Young adults aged 18 to 25: _____________

105.4. Adults aged 26 and older: _____________

105.5. Age unknown: ___________

106. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 103. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

106.1. American Indian or Alaska Native: _____________

106.2. Black or African American: _____________

106.3. White: _____________

106.4. Asian: _____________

106.5. Native Hawaiian or Other Pacific Islander: ______________

106.6. Multiracial: ___________

106.7. Other: _____________

50.8. Race unknown: ___________

107. Of the total number of participants reached by this environmental strategy intervention during the past Federal fiscal year (reported in Question 103), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 103. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

107.1. Hispanic, Latino/a, or of Spanish origin: ____________

107.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

107.3. Hispanic ethnicity unknown: ____________

Information Dissemination Sub-Form

Questions in this section are only asked for each intervention categorized as an information dissemination intervention (see Q28e) and also categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

Name of Prevention Intervention: _________________________________E (autofill from Question 28)

Service Type: ___________________________________________ E (autofill from Question 28)

This sub-form focuses on information dissemination activities to change community attitudes, build awareness of substance use issues to reduce their incidence and prevalence, and change behavior. The strategy is characterized by one-way communication from source to audience. Report all media and communication campaigns (e.g., social marketing campaigns) in this section.

Please report on information dissemination activities that directly relate to educating policymakers about policies, laws, or regulations as environmental strategies for CSAP strategy type in item 28 and complete that sub-form. Note that publicity for specific environmental strategies (e.g., fliers to promote the installation of a new prescription drug box or a drug take-back day) should not be reported as a separate information dissemination activity. However, if you conduct an information dissemination campaign to promote use of existing prescription drug drop boxes, you would report that in this Information Dissemination sub-form.

108. What was/were the intended purpose(s) of the communication or information that you disseminated for this service type? (Select all that apply.)E

  • To raise awareness of prescription drug misuse problems in the community

  • To gain support from the community for prescription drug misuse prevention efforts

  • To provide information on community norms related to prescription drug misuse

  • To provide information on the dangers of sharing medications and misusing prescription drugs

  • To provide prescription drug misuse prevention information (e.g., information on securing prescription drugs in the household, information on resisting offers for sharing prescription/pharmaceutical drugs)

  • To change individual behaviors with regard to prescription drug misuse

  • To provide prevention intervention program information (e.g., contact information, meeting times)

  • To provide surveillance and monitoring information (e.g., information about whom to contact if you suspect prescription drug diversion)

  • To provide a directory of community resources for prevention of prescription drug misuse

  • Other (Describe.)


109. For this intervention-service type activity, indicate the community members and groups (i.e., target audience) to whom you disseminated the information during the past Federal fiscal year. (Select all that apply.)E

  • Health care providers/medical community

  • Pharmacists/pharmacy community

  • The general public

  • Youth groups or representatives

  • Schools or school districts

  • Youth-serving organizations other than schools (e.g., Big Brothers/Big Sisters, Boy Scouts/Girl Scouts)

  • Parents, family, or caregiver groups

  • Organizations serving seniors/older population

  • Advocacy volunteers

  • Business community

  • Media (e.g., radio and television stations, newspapers and magazines)

  • Faith-based organizations (e.g., churches, charitable organizations with religious affiliations such as Catholic Charities)

  • Civic or volunteer organizations (e.g., Kiwanis, Fraternal Order of Police, Women’s League, local sports or neighborhood associations)

  • LGBTQ-supportive organization

  • Military or veteran organization

  • Law enforcement agencies (e.g., local, tribal, state, and Federal law enforcement agencies, including the police, the Federal Bureau of Investigation [FBI], and the Drug Enforcement Administration [DEA],

  • Local or state, tribal, or jurisdiction courts

  • State departments of justice (e.g., judicial department, department of juvenile justice, department of criminal justice, attorney general’s office)

  • State, tribal, or local jails and prisons

  • State, tribal, jurisdiction, or local public health departments

  • Mental health professionals or agencies

  • Other state, tribal, or jurisdiction government agencies (e.g., public health, public safety, social services, American Indian tribal government)

  • Local, village, or tribal agencies (mayor’s office, city council, tribal council, Alaska Native Corporation agencies)

  • Other (Describe.)

110. Indicate the type(s) of individuals targeted by this information dissemination activity during the past Federal fiscal year. (Select all that apply.)E (autofill after first completed)

  • Middle school students

  • High school students

  • College students

  • Parents

  • Health care providers

  • Employees

  • Current or former military members

  • Military family members

  • Lesbian/gay/bisexual/transgender/questioning individuals (LGBTQ)

  • Individuals living in poverty

  • Individuals whose native language is other than English

  • Individuals with low literacy

  • Individuals with mental illness

  • Individuals with disabilities (e.g., hearing, visually, or physically impaired)

  • Other (Describe.)

111. For this information dissemination activity, did you create or air television ads during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 112-115.)

112. How many individual times did the television ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E

________ times

113. How many weeks did the television ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E

________ weeks

114. How many different televisions stations aired the ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E

________ stations

115. Provide any information you have on the reach of the television ads aired during the past Federal fiscal year. This could include information provided by the television stations or advertising agency on ratings points; the average number of viewers at the time the ads aired; the geographic area where the ads aired; and the target audience of the related television programs.E

(Describe; 3,000-character limit.)

116. For this information dissemination activity, did you create or air radio ads during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 117-120.)

117. How many individual times did the radio ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E

________ times

118. How many weeks did the radio ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E

________ weeks

119. How many different radio stations aired the ads air during the past Federal fiscal year? Insert “0” if ads were created but not aired during the period. This response should be written as a whole number (e.g., 4).E

________ stations

120. Provide any information you have on the reach of the radio ads aired during the past Federal fiscal year. This could include information provided by the radio stations or advertising agency on ratings points; the average number of listeners at the time the ads aired; the geographic area where the ads aired; and the target audience of the related radio broadcast.E

(Describe; 3,000-character limit.)

121. For this information dissemination activity, did you create or publish print ads during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 122-124.)

122. How many individual times did the print ads run during the past Federal fiscal year? (Select one response.)E

________ times

123. How many different newspapers or magazines displayed the ads during the past Federal fiscal year? Insert “0” if ads were created but not distributed during the period. This response should be written as a whole number (e.g., 4).E

________ newspapers or magazines

124. Provide any information you have on the reach of the print ads run during the past Federal fiscal year. This could include information provided by the newspaper or magazine on its average readership; the geographic area in which the publication was distributed; and the target audience of the publication.E

(Describe; 3,000-character limit.)

125. For this information dissemination activity, how many special events (e.g., invited speakers) were hosted during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ special events

126. For this information dissemination activity, how many other promotional activities (e.g., distributing prescription drug take-back information at a health fair) were implemented during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ promotional activities

127. For this information dissemination activity, did you present at community meetings (e.g., parent-teacher association [PTA] meetings, town hall meetings, school assemblies) during the past Federal fiscal year? Community meetings do not include regularly scheduled coalition meetings or coalition meetings held for planning purposes. (Select one response.)E

  • Yes

  • No (If selected, you will skip Questions 128 and 129.)

128. How many community meetings did you present at during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ meetings

129. What was the total number of participants at all community meetings where you presented during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ participants

130. For this information dissemination activity, did you send any letters to the editor of the local newspaper or community newsletters during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 131.)

131. How many letters were published during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ letters

132. For this information dissemination activity, did you produce or distribute prescription drug misuse prevention posters during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 133.)

133. How many posters were distributed during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

________ posters

134. For this information dissemination activity, did you produce or distribute prescription drug misuse prevention brochures during the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 135.)

135. How many brochures were distributed during the past Federal fiscal year? This response should be written as a whole number (e.g., 50).E

________ brochures

136. For this information dissemination activity, did you provide a related information line or hotline in the past Federal fiscal year? (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 136.)

136. How many individuals called into the information line or hotline in the past Federal fiscal year? This response should be written as a whole number (e.g., 50).E

________ individuals

137. For this information dissemination activity, did you develop or run a prescription drug misuse prevention-focused clearinghouse or information resource center in the past Federal fiscal year? (Select one response.) E

  • Yes

  • No

138. For this information dissemination activity, during the past Federal fiscal year, did you launch or maintain any web sites or post information on social media platforms focused on prescription drug misuse prevention? (Select all that apply.)E

  • Web site(s)

  • Facebook

  • Twitter

  • Instagram

  • TikTok

  • Tumblr

  • Snapchat

  • Other (Specify.) ___________

  • No (If selected, you will skip Question 139.)

139. What is the number of visitor sessions (visits) or interactions (e.g., likes, retweets, shares) that the web sites and platforms, had during the past Federal fiscal year? This response should be written as a whole number (e.g., 4).E

  • Specify number of visits/interactions _____

  • Do not know

140. For this information dissemination activity, did you conduct other communication activities during the past Federal fiscal year? E

  • Yes (Describe; 3,000-character limit.)

  • No

Overall Population of Focus reached by this intervention-service type

141. Estimate the total number of individuals who were reached or affected by this information dissemination activities for during the past Federal fiscal year. If you are unsure of the exact number of individuals affected, respond with your best estimate. This response should be written as a whole number (e.g., 4). (Note: this number should not exceed the sum of the populations of focus you reported in item 37.5 for this service type.)E

(Sum of reported populations of focus in item 37.5 for this service type:Prepopulate ___________________)

________ total individuals (If none, enter “0.”)

142. Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 141), indicate how many were female, male, and transgender. The number of females, males, transgender people, other, and unknown should add up to the total of participants reported in Question 141. These responses should be written as a whole numbers (e.g., 4) and not as percentages.E

142.1. Females: _____________

142.2. Males: ______________

142.3. Transgender: ______________

142.4. Other (Describe.): __________________ (Specify: _____________________)

142.5. Gender unknown: ______________

143. Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 141), indicate how many were in each of the age groups listed below. The number of children, youth, young adults, adults, and unknown should add up to the total of participants reported in Question 141. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

143.1. Children aged 0 to 11: _____________

143.2. Youth aged 12 to 17: _____________

143.3. Young adults aged 18 to 25: _____________

143.4. Adults aged 26 and older: _____________

143.5. Age unknown: ___________

144. Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 141), indicate how many were in each of the racial groups listed below. Ethnicity is counted separately from race; you will have an opportunity to report ethnicity in the next question. For example, if you served African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the African American race category. The number of American Indian/Alaskan Native, Asian, Black, Pacific Islander, and White, multiracial, other, and unknown should add up to the total of participants reported in Question 141. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

144.1. American Indian or Alaska Native: _____________

144.2. Black or African American: _____________

144.3. White: _____________

144.4. Asian: _____________

144.5. Native Hawaiian or Other Pacific Islander: ______________

144.6. Multiracial: ___________

144.7. Other: _____________

144.8. Race unknown: ___________

145. Of the total number of participants reached or affected by this information dissemination intervention during the past Federal fiscal year (reported in Question 141), indicate how many were Hispanic/Latino and how many were non-Hispanic/Latino. The number of Non-Hispanic/Latino, Hispanic/Latino, and unknown should add up to the total of participants reported in Question 141. These responses should be written as whole numbers (e.g., 4) and not as percentages.E

145.1. Hispanic, Latino/a, or of Spanish origin: ____________

145.2. Non-Hispanic, non-Latino/a, and not of Spanish origin: ____________

145.3. Hispanic ethnicity unknown: ____________


Implementation Barriers (Subrecipients Only )

Questions in this section are only asked if at least one intervention is categorized as active, completed or discontinued in the past federal fiscal year (see Q28g)

In this section, we would like to learn about challenges that had an impact on implementing SPF Rx interventions in your community during this reporting period.

146. How much did the following factors impact the progress or results of your SPF Rx efforts related to implementing interventions listed below in the past Federal fiscal year?E

Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you should check the box “No impact.”


Factors Impacting Intervention Implementation E

No impact

Low impact

Moderate impact

High impact

  1. Inadequate training/technical assistance to implement intervention

  1. Difficulty staffing implementation activities (e.g., delays in hiring, delays in training, turnover)

  1. Limited time for staff and team members to devote to implementation

  1. Implementing across too broad a geographic area

  1. Not enough grant funds to support implementation

  1. Limited ability to leverage other funds or in-kind donations to support implementation

  1. Difficulty coordinating or collaborating between grantee organization and subrecipients

  1. Difficulty coordinating or collaborating with other (non-grantee) public health and substance use agencies and coalitions

  1. Prioritization of prescription drug/opioid misuse treatment over prevention by public health and substance use agencies and coalitions

  1. Lack of prioritization of prescription drug/opioid misuse prevention by state leadership (e.g., governor's office, legislature)

  1. Difficulty getting buy-in and support from the medical community (e.g., health care professionals, medical or pharmacy boards and associations)

  1. Difficulty engaging health care providers or pharmacists

  1. Health care provider or pharmacist difficulty using PDMP data

  1. Health care provider or pharmacist perceptions about quality of PDMP data

  1. Difficulty getting schools, law enforcement, medical facilities, or other organizations on board to facilitate interventions

  1. Lack of relevant prevention interventions for specific disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Lack of relevant prevention interventions for specific high-need subpopulations (e.g., based on age, residential area, SES)

  1. Difficulty engaging disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Difficulty engaging high-need subpopulations (e.g., based on age, residential area, SES)

  1. Language barriers

  1. Cultural barriers

  1. Logistical barriers (e.g., space to delivery intervention, community member transportation to intervention)

  1. Cost of intervention (e.g., naloxone kits, prescription drug lock boxes)

  1. Lack of data to monitor interventions

  1. Stressful events affecting large portions of the community (e.g., natural disasters, Covid-19 related closures, other unexpected traumatic events) (Describe.) _________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________



Section 2D. Monitoring and Evaluation (Subrecipients only)

This section collects information on how you used your monitoring and evaluation findings.

147. Have you made changes to your SPF Rx prevention interventions or the implementation of your prevention interventions during the past Federal fiscal year as the result of the analysis of your monitoring and evaluation data? (Select one response.)E

  • Yes

  • No (If selected, you will skip Question 148.)

  • Data not yet collected or analyzed (If selected, you will skip Question 148.)

148. Which prevention intervention(s) did you modify—and how—during the past Federal fiscal year as the result of the analysis of your monitoring and evaluation data? E autofill with responses from 28a



Changed intervention (Select all that apply.):

  • [INTERVENTION NAME HERE] (Describe change.) ___________________________________________

  • [INTERVENTION NAME HERE] (Describe change.) ___________________________________________

  • [INTERVENTION NAME HERE] (Describe change.) ___________________________________________

  • [INTERVENTION NAME HERE] (Describe change.) ___________________________________________

  • [INTERVENTION NAME HERE] (Describe change.) ___________________________________________

149. Did you or your local evaluator work on any of the following intervention evaluation activities related to process or outcomes evaluation of your SPF Rx interventions during the past Federal fiscal year? Process evaluation focuses on how an intervention was implemented and operates. Outcome evaluation looks at the effect of your interventions on your targeted consumption, consequence, or intervening variables. (Select all that apply.) E

  • We did not conduct evaluation activities related to SPF Rx during the past Federal fiscal year

Evaluation activity

Process evaluation

Outcome evaluation

149.1. Develop or substantially revise an evaluation plan

149.2. Collect data

149.3. Analyze data

149.4. Produce an evaluation report

149.5. Not applicable; no work done in past Federal fiscal year

Evaluation Barriers

Questions in this section are only asked if at least one evaluation activity is marked as having been worked on in the past Federal Fiscal year (see Q149)

In this section, we would like to learn about barriers and challenges that impacted evaluation of prevention interventions in your community, state, tribal area, or jurisdiction during this reporting period.

150. How much did the following factors impact the progress or results of your SPF Rx efforts related to evaluating prevention interventions in the past Federal fiscal year?E

Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you should check “No impact.”


Factors Impacting Intervention Evaluation E

No impact

Low impact

Moderate impact

High impact

  1. Inadequate training/technical assistance to evaluate interventions

  1. Difficulty staffing evaluation activities (e.g., delays in hiring, delays in training, turnover)

  1. Limited time for staff and team members to devote to evaluation activities

  1. Evaluating across too broad a geographic area

  1. Not enough grant funds to support evaluation activities

  1. Limited ability to leverage other funds or in-kind donations to support evaluation activities

  1. Difficulty coordinating or collaborating between grantee organization and subrecipients

  1. Difficulty coordinating or collaborating with other (non-grantee) public health and substance use agencies and coalitions

  1. Difficulty accessing data on outcomes and consequences (e.g., PDMP data, hospital overdose data)

  1. Difficulty obtaining data specific to disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Difficulty obtaining data specific to high-need subpopulations (e.g., based on age, residential area, SES)

  1. Mismatch between level of disaggregation of available data (e.g., at state level) and level of project implementation (e.g., in counties within state)

  1. Difficulty analyzing data on outcomes and consequences (e.g., PDMP data, hospital overdose data)

  1. Poor quality of data on outcomes and consequences (e.g., PDMP data, hospital overdose data)

  1. Difficulty engaging health care providers and pharmacists

  1. Difficulty engaging disparate populations (e.g., based on race, ethnicity, sex, LGBTQ status)

  1. Difficulty engaging high-need subpopulations (e.g., based on age, residential area, SES)

  1. Lack of data to evaluate interventions

  1. Stressful events affecting large portions of the community (e.g., natural disasters, COVID-19 related closures, other unexpected traumatic events) (Describe.) _________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________

  1. Other (Describe.) ___________________


Section 3: Broad Contextual Factors (Both grantees and subrecipients complete)

In this section, we would like to learn about broad contextual factors that have had an impact on SPF Rx activities and outcomes in your community, state, tribal area, or jurisdiction during this reporting period.

151. How much impact did the following factors have on the progress or results of your SPF Rx efforts during the past Federal fiscal year? (Select one level of impact for each factor.)E

Note: If a specific item is not yet applicable or you do not know the answer yet based on your stage of implementation, you should check the box “No impact.”

SPF Rx108. Broader Contextual Factors

No impact

Low impact

Moderate impact

High impact

151.1. Lack of available mental health treatment (i.e., leading to self-medicating)

151.2. Lack of available substance use treatment

151.3. Lack of access to medical care and better treatment options for chronic medical conditions, including pain

151.4. Lack of community awareness of the risk factors, extent, or consequences of prescription drug/opioid misuse

151.5. Easy access to prescription drugs for misuse

151.6. Lack of trust in government agencies (i.e., public health authorities, social services, or law enforcement)

151.7. High poverty rates/low SES

151.8. High unemployment, underemployment, or economic dislocation

151.9. Low literacy or low education levels

151.10. Community social disorganization

151.11. Social isolation

151.12. Lack of opportunities for area youth

151.13. Cultural norms, attitudes, or practices favoring substance use

151.14. Cultural norms, attitudes, or practices that are resistant to identifying and serving individuals involved with substance use

151.15. Stigmatization of individuals involved in substance use in the community

151.16. Stressful events affecting large portions of the population of focus (e.g., natural disasters, COVID-19 related closures, other unexpected traumatic community events) (Describe.) _________________

151.17. Historical trauma experienced by racial/ethnic groups

151.18. Other (Describe.) __________________
_________________________________

151.19. Other (Describe.) __________________
_________________________________

151.20. Other (Describe.) __________________
_________________________________



Section 4: Closing Questions (Both grantees and subrecipients complete)

152. Provide any additional comments about your SPF Rx–related prevention intervention activities here. (Describe; 3,000-character limit.) E

153. Do you have any additional comments about any aspects of the SPF Rx Initiative? (Describe; 3,000-character limit.) E




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCLI Part 1 Revision
AuthorDACCC
File Modified0000-00-00
File Created2023-08-30

© 2024 OMB.report | Privacy Policy