Information and Directions

Each sub-recipient community will complete a separate Part II form for each prevention strategy implemented. For example, if the community is implementing both a participant-based education prevention strategy and an environmental prevention strategy, they will complete two Part II forms. Similarly, if the community is implementing two different participant-based education prevention strategies, they will also complete two separate Part II forms.

Each sub-recipient community will be assigned a unique identification. This identification will be used to link together all the data collected from a community throughout the grant period without the need to identify the community by name. Each prevention strategy will also be assigned a unique identification number. This identification will be linked to participant level data in order to provide a more complete understanding of each type of strategy used within an intervention implemented by sub-recipient communities. No individuals will be identified in the reporting of results.

Prevention Strategy Information


Prefilled Fields

The following fields will be automatically filled when the respondent clicks on the subform for strategies entered in CLI Part I
  • Name of Prevention Intervention
  • Name of Strategy
  • Unitque Identifier
  • Strategy Type

Item 1a.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Check all of the consumption patterns and/or consequences that you are targeting through your implementation of this prevention strategy. The only consumption patterns and consequences that will appear as options in this list are those that you indicated in CLI Part I as factors targeted by your community.

Item 1b.

(Answer at baseline, it will be automatically filled in by the database at follow-up.) Check all the intervening variables that the intervention strategies are designed to target.

Item 2.

(Answer at baseline and follow-up. It will be automatically filled in by the database at subsequent follow-ups.) Fill in the MM/YYYY to indicate the date you began funding this prevention strategy.

Item 3a.

(Answer at baseline and follow-up. It will be automatically filled in by the database at subsequent follow-ups.) Check “yes” or “no” to indicate whether you have completed (ended) implementation of this prevention strategy. This would include if the intervention was successfully implemented and is no longer continuing, or if the implementation was discontinued without resolution. If you select “no” you will automatically skip to item 4.

Item 3b.

(Answer at baseline and follow-up. It will be automatically filled in by the database at subsequent follow-ups.) Specify the month and year (MM/YYYY) the strategy was completed.

Item 4.

(This item will be automatically filled in by the database based on respondent’s earlier designation of the strategy while completing CLI Part I.) Check “yes” or “no” to indicate whether this strategy is part of a multi-strategy intervention.

Item 5.

(Answer at baseline and follow-up.) Check “yes” or “no” to indicate whether this is an evidence-based program, policy or practice or a component of a multi-strategy evidence-based program, policy or practice

An evidence-based program, policy or practice is an intervention that is theory-driven, has activities related to the theory of change underlying the program model, has been well implemented, and has produced empirically verifiable positive outcomes. . If “no” you will automatically skip to item 7.

Item 6.

(Answer at baseline and follow-up.) Check all of the ways you determined this was an evidence-based program, policy or practice or a component of one. If you knew from a criterion not listed, please check “other” and describe.

Item 7.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Check the one choice that best describes the implementation history of this prevention strategy in your community.

Item 8.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Check “yes” or “no” to indicate whether this prevention strategy includes a curriculum or manual. By curriculum or manual, we mean a set of instructions about how to deliver the prevention intervention This can be a pre-existing curriculum or manual created by the prevention intervention developer or a formal curriculum or manual developed by the community partner.

Items 9-13.

(Answer at baseline. These will be automatically filled in by the database at follow-up.) For items 9 through 13, indicate the geographic area(s) being served by this prevention strategy and the estimated population of the area(s). You are required to include zip codes (item 11) for all areas being served by this prevention intervention. If your target population is the entire state/tribe/jurisdiction you may enter “statewide” “tribe” or “jurisdiction” for item 11. This is for purposes of reporting to the Center for Substance Abuse Prevention (CSAP). Use one line to describe each area. Other than zip code, you only need to complete those categories that are appropriate for your prevention intervention and community served.


Item 14.

(Answer at baseline and follow-up.) Write in a number rounded to the nearest dollar (e.g., 43000—do not enter a dollar sign) to indicate the total cost of this prevention strategy during this reporting period—including planning, development, implementation, and evaluation. Make sure to include overhead and salary costs in the amount. If you do not know the exact amount spent, respond with the best numeric estimate.


Item 15.

(Answer at baseline and follow-up.) Write in as a whole number approximately what percentage of total funding for this prevention intervention comes from SPF SIG funds. For example, if you received about a third of your funding for this prevention intervention from SPF SIG funds, you would write in “33”. Do not use ‘%’ when entering your response. If you do not know the exact amount allocated, respond with your best estimate.

Adaptations

This section asks for information about any adaptations you made to this evidence-based program, policy, or practice. We understand that making adaptations to a prevention strategy can help make it more accessible to a specific population and we would like your honest answers about adaptations you may have made. Adaptations may include changes in target population, content, cultural appropriateness, dosage, duration, or setting of the prevention strategy that are different from those recommended by the prevention intervention developer.

Item 16.

(Answer at baseline and follow-up. It will be automatically filled in by the database at follow-up.) Check “yes” or “no” to indicate whether this is a new intervention developed and tested by you, the community partner. Some communities are funded to create new interventions for specific target populations, substances, and consequences that have been identified as problem areas in the community. If your intervention is one you developed and have tested or are planning on testing with a target population select “yes.” You will then automatically go to item 30.

Item 17.

(Answer at baseline and follow-up. It will be automatically filled in by the database at follow-up.) Check “yes” or “no” to indicate whether you made any adaptations to the prevention strategy. Examples of adaptations include delivery to a target population that was not indicated by the developer; changing curriculum content, dosage, or duration; or delivering in a setting not intended by the developer. If you select “no” you will automatically skip to item 28.


Item 18.

(Answer at baseline and follow-up.) Select the one response that applies to whether you adapted the prevention strategy in order to deliver it to a target population that was not indicated by the developer. (Examples of adaptations include targeting an age group younger than the indicated target population or targeting pregnant teens as opposed to young adults ages 18–24 as indicated by the developer.)

Item 19.

(Answer at baseline and follow-up.) Select the one response that applies to whether you made any adaptation to the curriculum or manual content of the prevention strategy.

Item 20.

(Answer at baseline and follow-up.) Select the one response that applies to whether you changed the recommended dosage for this prevention strategy (e.g., the number of sessions or number of public service announcements (PSAs) or other media spots). If you select the 3rd choice, “developer makes no recommendations . . . “ you will automatically skip to item 22.

Item 21.

(Answer at baseline. Number will be auto filled at follow-up) In 100 characters or less write in the recommended dosage. For example, if a strategy consists of 10 sessions, write in “10 sessions.”

Item 22.

(Answer at baseline and follow-up.) In 100 characters or less write in the dosage actually delivered.

Item 23.

(Answer at baseline and follow-up) Select the one response that applies to whether you changed the recommended duration for this prevention strategy (e.g., the number of days or hours per implementation cycle). If you select the third response, “prevention intervention developer makes no ...” you will automatically go to item 26.

Item 24.

(Answer at baseline. Number will be auto filled at follow-up) Write in as a whole number the recommended duration in hours, of this prevention intervention (e.g., 8). Please write in the total duration adding all sessions in a cycle together rather than the length of a single session. For example, if the developer recommends 10 sessions that are 2 hours in length, you would write “20.”

Item 25.

(Answer at baseline and follow-up) Write in as a whole number the number of hours actually spent delivering the prevention intervention strategy. Please write in the total duration adding all sessions in a cycle together rather than the length of a single session. For example, if you are actually delivering the strategy in 10 sessions that are 1 hour in length, you would write “10.”

Item 26.

(Answer at baseline and follow-up) Select the one response that indicates whether you changed the recommended setting of the prevention intervention strategy (e.g., the strategy was intended for delivery in a classroom setting, but you delivered in a community setting.)

Item 27.

(Answer at baseline and follow-up.) Select either “yes” or “no” to indicate whether adaptations were made to address the cultural appropriateness of the prevention intervention strategy for a particular group.


Item 28.

(Answer at baseline and follow-up.) Answer “yes” or “no” to indicate whether you collected information regarding participant satisfaction with the cultural appropriateness of the prevention intervention. If you select “no” you will automatically skip to item 30.

Item 29.

(Answer at baseline and follow-up.) Select the one response that best describes the results of the assessment of participants’ satisfaction with the cultural appropriateness of the prevention intervention. The results of an assessment of the cultural appropriateness of a prevention intervention will vary greatly. For this reason, we have included broad response options of highly satisfied, moderately satisfied, and not satisfied. We ask that you analyze the results of your particular assessment and choose the category that best corresponds to the overall results of your assessment.

Prevention Intervention Outcomes

This section pertains to the collection of outcome data. Outcome data is information that reveals the extent of change in targeted attitudes, values, behaviors, or conditions between baseline measurement and subsequent points of measurement. Depending on the nature of the prevention intervention and the theory of change guiding it, changes can be immediate, intermediate, final, or longer-term outcomes. If the evaluation for your prevention intervention strategy was conducted at the state/tribe/jurisdiction level, you may need to collaborate with the state level grantee organization (at the state/tribe/jurisdiction level) in order to complete items 30 through 33.

Item 30.

(Answer at baseline and follow-up.) Answer “yes” or “no” to indicate whether any outcome data were collected during this reporting period. This includes pretest, exit, and follow-up data, as well as other types of data. If you select “no” you will automatically go to item 34. Typically you will select, "Yes."


Item 31.

(Answer at baseline and follow-up.) Select all responses that apply to the sampling strategy you used for collecting outcome data. If you select “some other population or subgroup” please describe.

Typically, you will select the first response, "The entire target population for the prevention intervention strategy."

Item 32.

(Answer at baseline and follow-up.) Select all the listed Center for Substance Abuse Prevention (CSAP) National Outcome Measures (NOMs) that you collected during this reporting period.

Typically you will select the following responses for this item:
    • Drug-related crime
    • Alcohol-related car crashes and injuries
    • Number of persons served by age, gender, race and ethnicity
    • Total number of evidence-based programs, policies, or practices

Item 33.

Answer either “yes” or “no” to indicate whether an analysis of outcome data was completed during this reporting period. This analysis could have been completed by the community partner, the state/tribe/jurisdiction, or some other entity. In addition, this analysis could have been conducted by someone paid through the SPF SIG funds, or someone who was providing their services free-of-charge or as an in-kind contribution.

Closing Question


Item 34.

(Answer at baseline and follow-up.) Provide any additional comments about your prevention intervention activities here in 3000 characters or less.

Prevention Education Sub-Form

Item 35.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Write in the month and year (as MM/YYYY) when you first started serving participants with this Prevention Education intervention strategy, including all cycles.

Item 36.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Select either “yes” or “no” to indicate whether this is a recurring prevention intervention strategy, in which the same group of people is served over multiple sessions. An example would be a prevention intervention that is delivered to the same group of participants every Monday night for 6 weeks or to an 8th grade health class every Friday in a semester.

Item 37.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Select either “yes” or “no” to indicate whether this prevention intervention strategy is implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year. If your prevention intervention takes place for a period of time with the same participants and then starts over with new participants, select “yes.” A prevention intervention strategy can be both recurring and implemented in a series of cycles. If you select “no” you will automatically skip to question 38.

Item 37a.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Select the one response that best describes what the cycles for the recurring prevention intervention strategy in question 37 are based upon. Select “other’ and describe if the options offered do not fit.

Item 38.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Select the one response that describes how you would classify this prevention intervention strategy as delivered according to the Institute of Medicine categories. Universal strategies are designed for everyone in the eligible population, both the general public and all members of specific eligible groups. Universal strategy recipients are not identified on the basis of individual risk. Selective strategies are targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average. Indicated strategies are designed for persons who are identified as having minimal but detectable signs or symptoms or precursors of some illness or condition, but whose condition is below the threshold of a formal diagnosis of the condition.


Item 39.

(Answer at baseline and follow-up.) Select all the responses that describe the format of the prevention education intervention strategy used during this reporting period. If you used a format not listed, check “other” and describe.

Item 40.

(Answer at baseline and follow-up.) Select all the responses that indicate the types of participants served by this prevention intervention strategy during this reporting period. If you served another type of participant not listed, check “other” and describe.

Item 41.

(Answer at baseline and follow-up.) Write in as a whole number (not a fraction) how many groups of participants started the prevention education intervention strategy during this reporting period. Do not include groups counted in previous reporting periods.

Item 42.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number (not a fraction) how many groups of participants completed the prevention education intervention strategy during this reporting period. Do not include groups counted in previous reporting periods.

Item 43.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number (not a fraction) the total number of sessions provided for all groups of participants in the prevention education intervention strategy during this reporting period.

Item 44.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number (not a fraction) the average length of the individual sessions, in hours, during this reporting period.

Item 45.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number how many new participants were served by this prevention strategy during this reporting period. New participants are participants who had not received or participated in the prevention intervention in previous reporting periods and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. (If none, enter ‘0’—you will automatically skip to the end of this sub-form).

Item 46.a-c.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number the total number of new participants served by this prevention strategy during this reporting period who were in each of the gender groups listed below in a-c. The sum of the numbers reported in a-c should add up to the total number of new participants reported in question 45.

Item 47.a-f.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write in as a whole number the total number of new participants served by this prevention strategy during this reporting period who were in each of the age groups listed in a-f. The sum of numbers reported in a-f should add up to the total of new participants reported in question 45.

Item 48 a-h.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write as a whole number the total number of new participants served by this prevention strategy during this reporting period who were in each of the racial groups listed below in a-h. The sum of the numbers reported in a-h should add up to the total number of new participants reported in question 45. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the race category under African American.



Item 49 a-c.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of new participants served by this prevention strategy during this reporting period who were in each of the ethnic categories listed in a-c. The sum of the numbers reported in a-c should add up to the total number of new participants reported in question 45.

Alternative Drug-Free Activities Sub-Form

Item 50.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Write in the month and year (as MM/YYYY) when you first started serving participants with this Alternative Drug-Free Activities prevention intervention strategy, including all cycles.

Item 51.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Answer either “yes” or “no” to indicate whether the alternative drug-free activities are targeted at a specific group, such as high school students, college students, etc. If you answer “no” you will skip to item 66.

Item 52.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Answer either “yes” or “no” to indicate whether these are recurring activities, in which the same group of people is served over multiple prevention intervention strategy sessions.

Item 53.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Answer either “yes” or “no” to indicate whether this prevention intervention strategy was implemented in a series of cycles, in which a new group of participants is served on a regular schedule, such as a new school year. If you answer “no” you will automatically skip to item 54.

Item 53a.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Select the one response that best describes what the cycles in item 53 are based upon. If other than the options offered, select “other” and describe.

Item 54.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Select the one response that indicates how you would classify this prevention intervention strategy as delivered according to the Institute of Medicine categories. Universal strategies are designed for everyone in the eligible population, both the general public and all members of specific eligible groups. Universal strategy recipients are not identified on the basis of individual risk. Selective strategies are targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average. Indicated strategies are designed for persons who are identified as having minimal but detectable signs or symptoms or precursors of some illness or condition, but whose condition is below the threshold of a formal diagnosis of the condition.


Item 55.

(Answer at baseline and follow-up.) Select all that apply to the format of the alternative drug-free activities prevention intervention strategy during this reporting period. If in a format not listed, select “other” and describe.

Item 56.

(Answer at baseline and follow-up.) Select all the choices that indicate the types of participants served by this prevention intervention strategy during this reporting period. If another category not listed applies, check “other” and describe.

Item 57.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number how many groups of participants started the alternative drug-free activities prevention intervention strategy during this reporting period. Do not include groups counted in previous reporting periods.

Item 58.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number how groups of participants completed the alternative drug-free activities prevention intervention strategy during this reporting period. Do not include groups counted in previous reporting periods.

Item 59.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of sessions provided for all groups of participants in the alternative drug-free activities prevention intervention strategy during this reporting period.

Item 60.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of
hours provided for all groups of participants in the alternative drug-free activities prevention intervention strategy during this reporting period.

Item 61.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of new participants who were served by this prevention intervention strategy during this reporting period. New participants are participants who had not received or participated in the prevention intervention in previous reporting periods and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. If none, enter 0. You will automatically skip to the end of the subform.

Items 62 a-c.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number how many of the new participants served by this prevention intervention strategy during this reporting period were in each gender group listed in a-c. The sum of the numbers in a-c should equal the total number of new participants reported in item 61.

Items 63.a-e

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of new participants served by this prevention intervention strategy during this reporting period; to indicate how many were in each of the age groups listed below in a-e. The sum of a-e equal the total number of new participants reported in item 61.

Items 64 a-h.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of new participants served by this prevention intervention strategy during this reporting period that were in each of the racial groups listed in a-h below. The sum of the numbers in a-h should equal the total number of new participants reported in item 61. You will have an opportunity to report ethnicity in the next item. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the race category under African American.



Items 65.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of new participants served by this prevention intervention strategy during this reporting period, that were listed in ethnic groups a-c. The sum of a-c should equal the number of new participants reported in item 61.

Item 66.

(Answer at baseline and follow-up. You may add into the database on an ongoing basis at any time, or enter at the end of reporting period.) Check “yes” or “no” to indicate whether you conducted drug-free events (concerts, festivals/fairs, picnics, sporting events) during this reporting period that were not targeted to specific groups of participants during this reporting period. If “no” you will automatically skip to the end of this subform.

Item 67.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of drug free events that were conducted during this reporting period.

Item 68.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write as a whole number the total number of people who were reached through the drug free events during this reporting period.

Problem Identification and Referral Sub-Form

Item 69.


(Answer at baseline. It will be automatically filled in by the database at follow-up.) Write in the month and year (as MM/YYYY) when you first started serving participants with this problem identification and referral prevention intervention strategy, including all cycles.

Item 70.


(Answer at baseline and follow-up.) Select all the responses that indicate the types of participants served by the problem identification and referral prevention services during this reporting period. If you served another type not listed check “other” and describe.

Item 71.


(Answer at baseline and follow-up.) Select all the responses that indicate the location(s) in which problem identification and referral services took place. If you provided services at a location not listed, check “other” and describe.

Item 72.


(Answer at baseline and follow-up.) Select all the responses that indicate the types of services to which individuals were referred. If they were referred to a service other that those listed, please check “other” and describe.

Item 73.


(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number the total number of individuals for whom problem identification and referral services were provided during this reporting period. This includes both new participants and participants who began services in a previous period.

Item 74.


(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write in as a whole number the total number of new participants served by this prevention intervention during this reporting period. New participants are participants who had not received or participated in the prevention intervention in previous reporting periods and were therefore not previously counted. If you are unsure of the exact number of new participants, respond with your best estimate. If none, enter 0. You will automatically skip to the end of sub-form.

Items 75.a-c


(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write in as a whole number (not a percentage) the number of individuals in each gender listed in a-c among the new participants served by problem identification and referral services during this reporting period. The sum of the numbers in a-c should equal the total number of new participants reported in question 74.

Items 76.a-e


(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write in as a whole number (not a percentage) the number of new participants served by this prevention intervention strategy during this reporting period how many were in each of the age groups listed below in a-e. The sum of the numbers in a-e should add up to the total number of new participants reported in question 74.

Items 77.a-h


(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write in as a whole number (not a percentage) the number of new participants served by problem identification and referral services during this reporting period in each racial group listed below in a-h. The numbers should add up to the total number of new participants reported in question 74. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the Hispanic ethnicity category and the race category under African American.

Items 78.a-c


(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.)Write in as a whole number (not a percentage) the number of new participants served by problem identification and referral services during this reporting period who were in each ethnic group listed below in a-c. The sum of the numbers in a-c should equal the total of new participants reported in question 74.

Community-Based Processes Sub-Form

Item 79.

(Answer at baseline and follow-up.) Check “yes” or “no” to indicate whether you did any work related to task forces of coalitions during this reporting period. If “no” you will automatically skip to question 83.

Item 80.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of task force/coalition members you recruited during this reporting period, if any. If none, enter 0.

Item 81.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of taskforce/coalition meetings you held during this reporting period. If none, enter 0.

Item 82.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of task force/coalition members you trained during this reporting period, if any. If none, enter 0.

Item 83.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of community members, other than task force/coalition members, you trained during this reporting period, if any. If none, enter 0.

Item 84.

(Answer at baseline and follow-up.) Check “yes” or “no” to indicate whether you coordinated funding with other organizations during this reporting period.

Item 85.

(Answer at baseline and follow-up.) Check “yes” or “no” to indicate whether you developed any prevention or provider networks during this reporting period.

Item 86.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of outreach/education sessions you hosted during this reporting period, if any. Do not include outreach or education sessions that are counted or reported in another section of this instrument. If none, enter 0.

Item 87.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of community organizations to whom you provided funding or other in-kind donations during this reporting period, if any. If none, enter 0 and you will automatically proceed to question 88.

Item 88.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the total amount of funding you provided to community organizations during this reporting period. (Include in-kind donations.) Please round the numbers to the nearest dollar, e.g. 36,000.

Item 89.

(Answer at baseline and follow-up.) Write in as a whole number (not a percentage) the number of community organizations to whom you provided technical assistance during this reporting period. If none, enter 0.

Item 90.

(Answer at baseline and follow-up.) Enter “yes” or “no” to indicate whether you reorganized local agencies to promote efficiency in delivering substance abuse prevention during this reporting period.

Item 91.

(Answer at baseline and follow-up.) Enter “yes” or “no” to indicate whether you reallocated local funds for substance abuse prevention during this reporting period.

Item 92.

(Answer at baseline and follow-up.) Enter “yes” or “no” to indicate whether you formally changed the ways local organizations work together to address substance abuse prevention during this reporting period, for example by officially changing school curricula or by documenting specific policies or practices for working together.

Item 93.

(Answer at baseline and follow-up.) Enter “yes” or “no” to indicate whether you monitored regulatory or compliance changes by the state/tribe/jurisdiction toward local or regional organizations during this reporting period.

Item 94.

(Answer at baseline and follow-up.) Enter “yes” or “no” to indicate whether conducted other community activities during this reporting period. If yes, please describe.

Item 95.

(Answer at baseline and follow-up.) Please write in a response to indicate how often you conducted other community activities during this reporting period. For example: once a week, twice a month, once per quarter, etc.

Item 96.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please write in an estimate of the total number of individuals who received or were affected by these other community activities during this reporting period.


Items 97.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals who received or were affected by these other community activities by gender in a-c below. Please write this percentage as a whole number. The sum of all the percentages in a-c should add up to 100%. Do not use % when entering your response.


Items 98.a-f
(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by age group in a-f below who received or were affected by these other community activities. Please write this percentage as a whole number. The sum of all the percentages in a-f should add up to 100%. Do not use % when entering your response.


Items 99.a-h

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by racial group listed below in a-h who received or were affected by these other community activities. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. Please write this percentage as a whole number (e.g., 20). The sum of all responses in a-h should equal 100%. Do not use ‘%’ when entering your response.


Items 100.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by ethnicity listed in a-c below who received or were affected by these other community activities. Please write this percentage as a whole number (e.g., 20). The sum of all responses in a-c should equal 100%. Do not use ‘%’ when entering your response.

Environmental Strategies Sub-Form

Item 101.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Please write in the month and year (MM/YYYY) when you first started conducting the environmental strategy.

Item 102.

(Answer at baseline and follow-up.) Select the one choice from the list below that describes the type of environmental strategy you conducted.


Item 103.

(Answer at baseline and follow-up.) Select all responses that indicate what individuals or organizations you worked with in planning or implementing the environmental strategy during this reporting period. If you used a strategy not listed, check “other’ and describe.

Item 104.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please provide an estimate of the total number of individuals who received or were affected by this environmental strategy during this reporting period. If you are unsure of the exact number of individuals affected, provide your best estimate.


Items 105.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please provide an estimate of the percentage of individuals listed below by gender in a-c who received or were affected by this environmental strategy during this reporting period. Please write this percentage as a whole number (e.g., 20). The sum of all percentages should be 100%. Do not use % when entering your response.


Items 106.a-f

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please provide an estimate of the percentage of individuals by age group listed below in a-f, who received or were affected by this environmental strategy during this reporting period. Please write this percentage as a whole number (e.g., 20). The sum of all percentages should be 100%. Do not use % when entering your response.


Items 107.a-h

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by racial group listed below in a-h who received or were affected by this environmental strategy by racial group. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. Please write this percentage as a whole number (e.g., 20). The sum of all responses in a-h should equal 100%. Do not use ‘%’ when entering your response.


Items 108.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by ethnic group listed in a-c below who received or were affected by this environmental strategy. Please write this percentage as a whole number (e.g., 20). The sum of all responses a-c should equal 100%. Do not use ‘%’ when entering your response.



Information Dissemination Sub-Form

Item 109.

(Answer at baseline. It will be automatically filled in by the database at follow-up.) Please write in the month and year (MM/YYYY) when you first started conducting information dissemination activities. Do not include activities or information that you have reported in other areas, such as the environmental strategies section.

Item 110.

(Answer at baseline and follow-up.) Select all the individuals and organizations listed below that you worked with in planning and/or implementing your information dissemination efforts during this reporting period. If you worked with someone not listed, select “other’ and describe.

Item 111.

(Answer at baseline and follow-up.) Select all the choices that describe what types of information you disseminated. If you disseminated information not on the list, please select “other” and describe.

Item 112.

(Answer at baseline and follow-up.) Select all the choices that describe the format of the information you disseminated. If not on the list, check “other” and describe.

Item 113.

(Answer at baseline and follow-up.) In 500 characters or less, describe the settings in which the information was disseminated. For example, the information may have been disseminated at a Parent Teacher Association meeting, a rock concert, a parade, etc.

Item 114.

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Write in as a whole number (not a fraction) the approximate number of individuals who received or were affected by the information dissemination strategy. If you are unsure of the exact number of individuals, please provide your best estimate.


Item 115.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please provide an estimate of the percentage of individuals by gender listed below in a-c who received or were affected by the information dissemination strategy during this reporting period. Please write this percentage as a whole number (e.g., 20). The sum of all percentages should be 100%. Do not use % when entering your response.

Item 116.a-f

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please provide an estimate of the percentage of individuals by age group listed below in a-f who received or were affected by the information dissemination strategy during this reporting period. Please write this percentage as a whole number (e.g., 20). The sum of all percentages should be 100%. Do not use % when entering your response.

Item 117.a-h

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by racial group listed below in a-h who received or were affected by the information dissemination strategy. You will have an opportunity to report ethnicity in the next question. Ethnicity is counted separately from race. For example, if you targeted African Americans of Hispanic ethnicity, they would be counted in both the ethnicity (Hispanic) category and the race category under African American. Please write this percentage as a whole number (e.g., 20). The sum of all responses in a-h should equal 100%. Do not use ‘%’ when entering your response.


Item 118.a-c

(Answer at baseline and follow-up. You may add numbers into the database on an ongoing basis at any time, or enter all at the end of reporting period.) Please estimate the percentage of individuals by ethnicity listed below in a-c who received or were affected by the information dissemination strategy. Please write this percentage as a whole number (e.g., 20). The sum of all responses should equal 100%. Do not use ‘%’ when entering your response.