> ![](media/image1.png){width="1.25in" height="1.1854166666666666in"}
> **Southwest CAPT**
>
> **555 E. Constitution Ste. 144**
>
> **Norman, OK 73072**
>
> **(800) 853-2572**

***[SWCAPT]{.smallcaps}***

***[Service to Science Academy]{.smallcaps}***

**[Summer 2008]{.smallcaps}**

**[Application Packet]{.smallcaps}**

######## 

######## 

######## 

######## Sponsored by:

######## Substance Abuse and Mental Health Services Administration

**Center for Substance Abuse Prevention**

**Southwest Prevention Center**

**CSAP's Southwest Center for the Application of Prevention
Technologies**

**TABLE OF CONTENTS**

> APPLICATION PROCEDURES. iii
>
> TIMETABLE FOR THE SPRING 2008 Service to
> Science...................................................\....iii

INSTRUCTIONS FOR PREPARING THE
APPLICATION.................................................................
1

> BASIC
> INSTRUCTIONS..................................................................................................1
>
> COVER
> SHEET...................................................................................................
> ...\.... 2
>
> ABSTRACT..................................................................................................................2
>
> PROGRAM NARRATIVE...
> .......................................................................................
> 2

A.  PHILOSOPHY..........................................................................................
    ..2

B.  NEEDS
    ASSESSMENT..............................................................................
    2

C.  POPULATION(S)
    SERVED........................................................................
    3

D.  GOALS AND
    OBJECTIVES........................................................................
    .3

E.  ACTIVITIES AND
    STRATEGIES...............................................................
    ..4

F.  EVALUATION (must include a logic
    model)............................................................ 5

G.  PROGRAM MANAGEMENT
    ...................................................................
    6

> H. APPLICATION COVER
> SHEET...................................................... \...7

APPENDIX A: DEFINITIONS OF IOM
DOMAINS......................................................... .......
8

APPENDIX B: STRATEGIC PREVENTION
FRAMEWORK........................................................ 9

APPENDIX C: EVIDENCE-BASED PRINCIPLES FOR SUBSTANCE ABUSE PREVENTION
.............. 10

APPENDIX D: RESOURCE
PUBLICATIONS........................................................................
11

APPENDIX E: LOGIC MODEL EXAMPLE 12

APPENDIX F: SOUTHWEST REGION NPN/TRIBAL REPRESENTATIVE S 13

APPENDIX G NPN/TRIBAL REPRESENTATIVE APPROVAL 15

APPENDIX H: APPLICATION CHECKLIST 16

***This application has been modified using NASADAD's Exemplary Awards
Application.***

ii

## Application Procedures

Applications for the Service to Science Academy may be obtained from
your Southwest CAPT state liaison, your state National Prevention
Network representative or the Southwest CAPT website
<http://captus.samhsa.gov/southwest/SWCAPTService2Science.cfm>.

All applications must be approved by your state's National Prevention
Representative (NPN) or Tribal Prevention Representative prior to
submission. **APPENDIX F** contains a listing of the **Southwest
Region's representatives and APPENDIX G** contains the approval form
needed to complete this application.

Applications for the Service to Science Academy must be electronically
mailed by close of business June11, 2008.

## 

## Timetable for the Service to Science Academy

June 11, 2008 Deadline for agencies to submit applications

June 23, 2008 Programs will be **notified** via e-mail & travel
information provided

August 4 & 5, 2008 Service to Science Academy

# INSTRUCTIONS FOR PREPARING THE APPLICATION

## BASIC INSTRUCTIONS

The Service to Science application is designed to solicit detailed,
descriptive information on how and why a program was created and
implemented, and to capture the processes that led to the program\'s
demonstrated success. This information will serve as the basis for
understanding the merits of the program. A list of resource publications
that can be consulted for information and references is included in
Appendix D.

Please keep the following considerations in mind as you prepare an
application:

1.  All responses should **be typed**, on only **one side** of the
    paper, **single-spaced** with **1-inch margins. All pages** should
    be **numbered**.

2.  The total application **must not exceed 22 pages** including the
    cover sheet, abstract, and logic model. Applications may be fewer
    pages, so long as **each of the application elements is addressed.**

3.  **Attachments or appendices are not allowed.** All attachments will
    be discarded and will not be reviewed as part of the application.

4.  Note that the **cover sheet requires signatures of the program and
    agency director**.

5.  Applicants must **follow the order and exact headings** as shown
    **below** to present information about their submitted program (A
    Table of Contents is [not]{.underline} mandatory; if included, it
    will not count toward the total page limit of the application.):

-   Cover Sheet

-   Abstract 2 pages

-   Program Narrative

    -   Philosophy

    -   Needs Assessment

    -   Population Served 20 page

    -   Goals and Objectives maximum

    -   Activities and Strategies

    -   Evaluation

    -   Logic Model

    -   Program Management

  -----------------------------------------------------------------------
  ***Note: Given the timetable and the need to obtain and review a
  significant amount of information, any application that does not adhere
  to these guidelines will not be considered for review.***

  -----------------------------------------------------------------------

## 

## COVER SHEET

## ABSTRACT

A **[single-spaced abstract not to exceed 30 lines]{.underline}** must
precede the narrative section of the application. The abstract should
provide readers with the following information: \"who - provides what -
to whom - how - when - where\" and the underlying rationale or model for
the program's approach, as well as highlights of the most pertinent
evaluation findings.

## PROGRAM NARRATIVE 

The narrative section should be written in a manner that is clear to
reviewers unfamiliar with the program. It should be well organized and
succinct and should contain sufficient information for reviewers to
fully understand the program. The narrative sections **[may not exceed
20 single‑spaced pages]{.underline}.**

### A. [Philosophy (10 points)]{.underline}

This section should describe the program's philosophical framework (or
its mission statement) and document its theoretical base and research
support in substance abuse and other fields to ensure accuracy,
efficacy, and credibility of approach. **[Please include a statement as
to the program\'s adherence to a message of no use of any illegal drug
or no illegal or high-risk use of alcohol or legal drugs.]{.underline}**

**The applicant should address the following questions:**

-   What is the philosophy, conceptual framework or mission statement on
    which the program is based?

-   How does the program\'s philosophy reflect a \"no illegal or
    high-risk use\" message for alcohol and drugs for ATOD prevention
    programs, or a "no high-risk behavior" message for other prevention
    programs?

### B. [Needs Assessment (35 points)]{.underline}

This section should describe the background leading to the program\'s
development; the gaps or needs the program fills; and how the program
integrates philosophy, empirical research, needs assessment, and
evaluation data into its ongoing planning. A brief description of
relevant prior work, observations, or experiences of the applicant
program should be included here.

**The applicant should address the following questions:**

-   What are the sound, long- and short-term planning processes that
    include a needs assessment and reflect a research base?

-   What epidemiological data and/or other information are available in
    the community that led to the establishment of this particular
    program?

### C. [Population(s) Served (25 points]{.underline})

-   This section should describe the population(s) to be served by the
    program. It should demonstrate that the audience to be served is
    well defined and understood by describing special characteristics of
    the population. What have you done to ensure cultural competency in
    this program or practice?

**The applicant should address the following questions:**

-   What target population(s) does the program serve? Please describe
    its norms, values, beliefs, practices, socioeconomic
    characteristics, risk and resiliency factors, cultural
    considerations, unique or special needs, and whether the program is
    community-wide or focuses on a specific population.

-   What was done to recruit and retain members of the targeted
    population into this program?

-   What actions were taken to involve representatives of the target
    population(s) in program planning and implementation to ensure that
    the program is responsive to their needs?

-   How is the staff trained in the cultural patterns of the program's
    target population(s)?

###  [Goals and Objectives (25 points)]{.underline}

This section should lay out the program\'s or organization\'s mission
statement followed by clearly stated, realistic, detailed, measurable,
and concise goals and objectives in the context of the mission
statement.

**The applicant should address the following questions:**

-   What are the goals and objectives of the program?

-   How do the goals and objectives address information gathered through
    a needs assessment?

-   

-   How many individuals/systems are expected to be reached and in what
    timeframe?

-   Do the outcomes reported relate back to the program's goals and
    objectives?

### E. [Activities and Strategies (35 points)]{.underline}

**If this program embodies activities or strategies categorized as
ENVIRONMENTAL (this should be appropriately indicated on the APPLICATION
COVER SHEET), please skip to the section indicated by the arrow.**

This section describes the approaches and methods used by the program to
accomplish the stated goals and objectives. Program applications must
clearly describe the strategies, activities, practices, or products
used, including the scope, intensity, and duration.

**The applicant should address the following questions:**

-   **[What makes this program innovative?]{.underline}** What features
    of the program distinguish it from similar programs? **[Please
    describe any innovative and unique features that respond to changing
    needs, new developments, state-of-the art standards in the
    prevention field, and the unique and special needs of population(s)
    described in the preceding section.]{.underline}**

-   What activities, strategies, materials, and products does the
    program employ to prevent substance abuse related problems or to
    foster environments in which the use of substances---particularly
    among youth---is discouraged or unacceptable?

-   Describe in detail how the program operates (including its scope,
    intensity, and duration), who is involved in conducting the
    activities (volunteers, staff, others), and identify all features
    critical to program implementation.

-   What aspects or elements of the program, if any, can be replicated
    or adapted to other sites? If so, how can this be achieved?

**This section describes the activities and strategies used by an
environmental program to accomplish the stated goals and objectives.
\[See the text box on Page 3\] If this program is categorized as
[ENVIRONMENTAL]{.underline} (this should be appropriately indicated on
the APPLICATION COVER SHEET), the applicant should address the following
questions in lieu of the above four questions (i.e., omit the previous
questions above in Section E and answer the following):**

-   **[What makes this strategy or practice innovative?]{.underline}**
    What features of the strategy or practice distinguish it from
    similar strategies or practices?

-   What is the infrastructure/support system used to implement this
    practice or strategy on a community-wide scale?

-   Does the environmental program have sufficient scale and scope to
    affect community-wide change? (e.g., is the level of outreach
    sufficient? Does the program succeed in changing community norms?
    Does the program or strategy have adequate capacity to elicit
    community-wide change?)

-   Is information provided on the number of individuals in the
    community, and what percent of these individuals were impacted
    through the implementation of this environmental strategy or
    practice?

-   What aspects or elements of the program can be replicated or adapted
    to other sites?

  -----------------------------------------------------------------------
  ***Note: Prevention strategies may include, but not be limited to,
  those pertaining to the domains of the Institute of Medicine --
  Universal, Selective, and Indicated. See Appendix A for definitions of
  these domain areas.***

  -----------------------------------------------------------------------

### F. [Evaluation (35 points)]{.underline}

This section should provide information on the program's effectiveness,
including verifiable data derived from information on the program\'s
process and outcome evaluation. If possible, the applicant should
provide a description of the program's evaluation plan. The evaluation
results should be congruent with the program's stated goals and
objectives, and should include quantifiable data. You **must include a
logic model** that reflects the programs inputs, strategies, short -
term, intermediate outcomes, and long - term impacts. The logic model
should reflect the program's underlying theory or philosophy and the
discussion should relate the logic model to evaluation processes and
data.

  -----------------------------------------------------------------------
  ***Note: Applicants are strongly encouraged to provide data from
  evaluations conducted within the last 2 years.***

  -----------------------------------------------------------------------

**The applicant should address the following questions:**

-   What are the major outcomes, impacts, and changes accomplished?

```{=html}
<!-- -->
```
-   What evidence can be used to support the claim(s) described above
    and the nature of change that was demonstrated?

-   How do you relate the outcomes described above to the program's
    goals and objectives?

-   How do the results meet the needs for which the program was
    designed?

###  [Program Management (including organizational chart and budget narrative)]{.underline}

### [(20 points)]{.underline}

-   This section should describe the organizational structure of the
    program and how it is managed in the context of resources needed to
    be successful. A demonstration of an organizational commitment to
    substance abuse issues should be discussed.

**CSAP's Southwest Center for the Application of Prevention
Technologies**

**Service to Science Academy**

###### APPLICATION COVER SHEET

***(TO BE INCLUDED WITH SUBMITTED APPLICATION)***

## [Program Information]{.underline}

**Is this application a re-submission from a previous year**? \[check
one\] \_\_\_\_YES \_\_\_\_NO

**What are the primary target(s) for this program**? \[check all that
apply\]

\_\_\_\_INDIVIDUAL \_\_\_\_SCHOOL/CAMPUS-BASED \_\_\_\_\_FAMILY/PARENT

\_\_\_\_PEER/GROUP \_\_\_\_WORKPLACE-BASED \_\_\_\_ENVIRONMENTAL\*
\_\_\_\_\_OTHER

**Does this application describe a community-based or environmental
program or strategy?**

> \[check one\] \_\_\_\_\_YES \_\_\_\_\_NO

  -------------- ----------------------------------------------------------
  **Program      
  Name:**        

  **Agency       
  Name:**        

  **Contact      
  Person:**      

  **Address:**   

  **Phone:**     

  **FAX:**       

  **Email:**     
  -------------- ----------------------------------------------------------

Please return to:

CSAP's Southwest CAPT

Attention: LaShonda Williamson

555 E. Constitution Ave

Ste. 144

Norman, OK 73072

**OR**

Electronically to:

<lwilliamson@ou.edu> and cc: <swpc@ou.edu>

> **Please, place Service to Science in the subject line.**

# Appendix A: Definitions of IOM Domains

In 1994, the National Academy of Sciences' Institute of Medicine (IOM)
developed a model describing the spectrum of services in the substance
abuse field. The spectrum ranges from prevention to treatment to
maintenance, and has become a useful model for service providers to
match services with need. Within the prevention portion of the spectrum,
the IOM has described three (3) domain areas for prevention
interventions, universal, selected, and indicated:

**Universal interventions** -- These interventions are designed to reach
an entire population or large audience. Such interventions or services
would be targeted toward people who are not identified to be at special
risk of developing a substance dependency. Examples include radio
messages, media campaigns,

**Selected interventions** -- These interventions target subgroups who
may be at risk of using or abusing substances. Examples of "selected"
subgroups include children of alcoholics, women of childbearing age,

**Indicated interventions** -- These interventions are meant to identify
individuals who are experiencing early signs or symptoms of substance
use or abuse, but do not yet meet the diagnostic criteria of substance
dependency.

# Appendix B: Strategic Prevention Framework

The **Strategic Prevention Framework (SPF)** is a SAMHSA paradigm that
is built on a community-based risk and protective factors approach to
prevention and a series of guiding principles that can be
operationalized at the Federal, State, and community levels. The SPF is
designed to:

-   Prevent the onset and reduce the progression of substance abuse,
    including childhood and underage drinking

-   Reduce substance abuse-related problems in communities

-   Build prevention capacity and infrastructure at the State and
    community levels

The SPF is a logical process that entails five (5) related processes:

**[Conduct a needs assessment]{.underline}** -- this step entails
developing a profile of community needs, resources, and readiness to
address the problems and gaps in service delivery. An important feature
of this step is the collection of epidemiological data that includes an
assessment of the magnitude of the substance abuse problem in the
community; assessment of risk and protective factors; assessment of
community assets and resources; identification of gaps in services and
capacity; assessment of readiness to act; identification of priorities;
and specification of baseline data against which progress and outcomes
can be measured.

**[Build capacity]{.underline}** -- this step entails the mobilization
and/or building of capacity to address needs. Important parts of this
step may include convening leaders and stakeholders; building
coalitions; training community stakeholders, coalitions, and providers;
and engaging stakeholders to help sustain the activities.

**[Develop a strategic plan]{.underline}** -- the strategic plan
articulates not only a vision for the prevention activities, but also
strategies for organizing and implementing prevention efforts. The plan
will need to be adjusted as the result of new information, and
sustainability should be a constant thought throughout each step of
planning and implementation.

**[Implement evidence-based programs]{.underline}** -- the findings of
the needs assessments in Step 1 will inform and selection and
implementation of policies, programs, and practices proven to be
effective in research settings and communities.

**[Evaluate]{.underline}** -- this final step involves monitoring
process, evaluating the effectiveness, and improving or replacing those
aspects that failed. Ongoing evaluation and monitoring are essential to
determine if the outcomes desired are achieved and to assess program
effectiveness and service delivery quality.

# 

# 

# 

# Appendix C: Evidence-Based Principles for Substance Abuse Prevention

# 

The following are evidence-based principles for the prevention of
substance abuse, as described by the Office of National Drug Control
Policy (2000):

Address appropriate risk and protective factors for substance abuse in a
defined population

1.  Define a population.

2.  Address levels of risk, protection, and substance abuse for that
    population.

3.  Focus on all levels of risk, with special attention to those exposed
    to high risk and low protection.

#### Use approaches that have shown to be effective

4.  Reduce the availability of illicit drugs, and of alcohol and tobacco
    for the under-aged.

5.  Strengthen anti-drug-use attitudes and norms.

6.  Strengthen life skills and drug refusal techniques.

7.  Reduce risk and enhance protection in families.

8.  Strengthen social bonding.

9.  Ensure that interventions are appropriate for the populations being
    addressed.

#### Intervene early at important stages and transitions

10. Intervene early and at developmental stages and life transitions
    that predict later substance abuse.

11. Reinforce interventions over time.

#### Intervene in appropriate settings and domains

12. Intervene in appropriate settings and domains.

#### Manage programs effectively

13. Ensure consistency and coverage of programs and policies.

14. Train staff and volunteers.

15. Monitor and evaluate programs.

# Appendix D: Resource Publications

AIDS Action. *What Works in HIV Prevention for Substance Users*, 2001,
***[http://www.aidsaction.org](http://www.aidsaction.org/)***

Center for Substance Abuse Prevention, Substance Abuse & Mental Health
Services Administration. *Science-Based Prevention Programs and
Principles*, 2002, DHHS publication #(SMA) 03-3764.

Hogan, Gabrielson, Luna, and Grothaus. *Substance Abuse Prevention: The
Intersection of Science and Practice*. Boston: Allyn & Bacon, 2003.

National Institute on Drug Abuse. *Preventing Drug Use Among Children
and Adolescents: A Research Based Guide for Parents, Educators, and
Community Leaders*, 2^nd^ edition, 2003.
***[http://www.drugabuse.gov](http://www.drugabuse.gov/)***

National Institute on Drug Abuse. *Principles of Drug Addiction
Treatment: A Research Based Guide*, October 1999, NIH publication
#99-4180

National Institute on Drug Abuse. *Monitoring the Future, volume I,
Secondary School Students* 1975 - 2004, September 2005, NIH Inventory \#
BKD527

National Institute on Drug Abuse. *Monitoring the Future, volume II,
College Students & Adults* 1975 - 2004, November 2005, NIH Inventory
#BKD528.

National Institute on Drug Abuse. *Principles of HIV Prevention in
Drug-Using Populations*, March 2002, NIH publication #02-4733

National Research Council, Institute of Medicine. *Reducing Underage
Drinking: A Collective Responsibility*, Washington: The National
Academies Press, 2004.

Office of Applied Studies, Substance Abuse & Mental Health Services
Administration. *National Survey on Drug Use and Health*, September
2005***. [http://www.oas.samhsa.gov](http://www.oas.samhsa.gov/)***

Office of National Drug Control Policy. *National Drug Control
Strategy*, February 2006.
***<http://www.whitehousedrugpolicy.gov/publications/policy/ndcs06>***

# Appendix E: Logic Model Example

+---------+--------+---------+---------+---------+--------+---------+
| *       | **     | *       | **      | **Sho   | *      | **Lo    |
| *Goal** | Strate | *Target | If-Then | rt-Term | *Mediu | ng-Term |
|         | gies** | Group** | State   | Out     | m-Term | Out     |
|         |        |         | ments** | comes** | Outc   | comes** |
|         |        |         |         |         | omes** |         |
+---------+--------+---------+---------+---------+--------+---------+
| Reduce  | Tut    | C       | If      | Learn   | Partic | I       |
| ATOD    | oring: | hildren | t       | study   | ipants | ncrease |
| use     | 3      | in      | utoring | skills. | use    | in      |
| through | hours  | grades  | is      |         | l      | a       |
| im      | per    | 1-3 at  | offered | Learn   | earned | cademic |
| proving | week   | x       | to      | time    | s      | perfo   |
| a       | for    | ele     | s       | man     | kills. | rmance. |
| cademic | one    | mentary | tudents | agement |        |         |
| achie   | school | school  | having  | skills. |        | In      |
| vement. | year:  | who are | a       |         |        | creased |
|         | 50     | str     | cademic | Learn   |        | school  |
|         | stu    | uggling | pr      | tips to |        | b       |
|         | dents. | academ  | oblems, | assist  |        | onding. |
|         |        | ically. | then    | with    |        |         |
|         |        |         | s       | fo      |        | Parti   |
|         |        |         | tudents | cusing. |        | cipants |
|         |        |         | will    |         |        | do not  |
|         |        |         | have    |         |        | begin   |
|         |        |         | the     |         |        | using   |
|         |        |         | oppo    |         |        | ATOD    |
|         |        |         | rtunity |         |        | within  |
|         |        |         | to      |         |        | three   |
|         |        |         | improve |         |        | years   |
|         |        |         | their   |         |        | after   |
|         |        |         | skills. |         |        | partic  |
|         |        |         | If they |         |        | ipating |
|         |        |         | improve |         |        | in the  |
|         |        |         | their   |         |        | p       |
|         |        |         | a       |         |        | rogram. |
|         |        |         | cademic |         |        |         |
|         |        |         | skill,  |         |        |         |
|         |        |         | they    |         |        |         |
|         |        |         | will    |         |        |         |
|         |        |         | not     |         |        |         |
|         |        |         | fail    |         |        |         |
|         |        |         | school  |         |        |         |
+---------+--------+---------+---------+---------+--------+---------+

+-----------------------------------+----------------------------------+
| ###### *ARKANSAS*                 | ####### **MISSOURI**             |
|                                   |                                  |
| Tommie Johnson Waters, Director   | Angie Stuckenschneider,          |
| of Prevention Services            | Prevention Coordinator           |
|                                   |                                  |
| AR Department of Health & Human   | MO Dept. of Mental Health        |
| Services                          |                                  |
|                                   | Division of Alcohol & Drug Abuse |
| Office on Alcohol & Drug Abuse    |                                  |
| Prevention                        | P.O. Box 687                     |
|                                   |                                  |
| 4313 West Markham - 3^rd^ Floor   | 1706 E. Elm Street               |
| Admin                             |                                  |
|                                   | Jefferson City, MO 65102         |
| Little Rock, AR 72205             |                                  |
|                                   | \(573\) 751-4105 **Fax:** (573)  |
| Direct (501) 686-9515 **Fax:**    | 751-7814                         |
| (501) 686-9396                    |                                  |
|                                   | **E-mail:**                      |
| **Email:**                        | <an                              |
| <tommie.waters@arkansas.gov>      | gie.stuckenschneider@dmh.mo.gov> |
|                                   |                                  |
| **cc:** <jo.warren@arkansas.gov>  |                                  |
+-----------------------------------+----------------------------------+
| ####### **COLORADO**              | ####### **NEBRASKA**             |
|                                   |                                  |
| Stan Paprocki, Director of        | Dave Palm                        |
| Prevention Services               |                                  |
|                                   | Prevention Program Manager       |
| Alcohol & Drug Abuse Division     |                                  |
|                                   | NE Health & Human Services       |
| CO Department of Human Services   |                                  |
|                                   | PO Box 94728                     |
| 4055 South Lowell Boulevard       |                                  |
|                                   | Lincoln, NE 68509-4728           |
| Denver, CO 80236-3120             |                                  |
|                                   | Phone: 402-479-5573 **Fax:**     |
| Ph(303) 866-7503 **Fax:** (303)   | 402-479-5162                     |
| 866-7481                          |                                  |
|                                   | **E-mail:**                      |
| **E-mail:**                       | <david.palm@hhss.ne.gov>         |
| [stan.paprocki@state.co.us](m     |                                  |
| ailto:stan.paprockil@state.co.us) | [ ]{.underline}                  |
|                                   |                                  |
|                                   | Mail: Lincoln Regional Center    |
|                                   |                                  |
|                                   | Prospector & Folsom              |
|                                   |                                  |
|                                   | Bldg 14                          |
|                                   |                                  |
|                                   | Lincoln, NE 68509-4728           |
+-----------------------------------+----------------------------------+
| ####### **KANSAS**                | ####### **NEW MEXICO**           |
|                                   |                                  |
| Joyce Cussimano, Director         | Don Maestas, Director            |
|                                   |                                  |
| Addiction & Prevention Services   | Office of Substance Abuse        |
|                                   | Prevention                       |
| Special Assistant for Health Care |                                  |
| Policy                            | Public Health Division           |
|                                   |                                  |
| KS Dept of Social &               | NM Department of Health          |
| Rehabilitation Services           |                                  |
|                                   | 1190 St. Francis Drive, Suite    |
| 915 SW Harrison 10 th Floor North | N3205                            |
|                                   |                                  |
| Topeka, KS 66612                  | Santa Fe, NM 87502               |
|                                   |                                  |
| \(785\) 368-6245 **Fax:** (785)   | \(505\) 827-2652 Fax: (505)      |
| 296-5507                          | 827-0097                         |
|                                   |                                  |
| **E-mail:**                       | **E-mail:**                      |
| <joyce.cussimanio@srs.ks.gov>     | [[donald.maes                    |
|                                   | tas@state.nm.us]{.underline}](ma |
|                                   | ilto:donald.maestas@state.nm.us) |
+-----------------------------------+----------------------------------+
| ####### **LOUISIANA**             | ####### **OKLAHOMA**             |
|                                   |                                  |
| Leslie H. Brougham, Ph.D., MSW    | Andrea LaFazia, Prevention       |
|                                   | Programs Director                |
| Director, Prevention Services     |                                  |
|                                   | OK Department of Mental Health & |
| Louisiana Office for Addictive    | Substance                        |
| Disorders                         |                                  |
|                                   | Abuse Services                   |
| Prevention Services               |                                  |
|                                   | P.O. Box 53277                   |
| 628 North 4^th^ Street            |                                  |
|                                   | Oklahoma City, OK 73152-3277     |
| # Baton Rouge, LA 70802           |                                  |
|                                   | **Fed Ex Mailing Address:**      |
| \(225\) 342-5705 **Fax:** (225)   |                                  |
| 342-3931                          | 1200 N.E. 13^th^ Street          |
|                                   |                                  |
| **E-mail:** <lbrougha@dhh.la.gov> | Oklahoma City, OK 73117          |
|                                   |                                  |
|                                   | \(405\) 522-4002 **Fax:** (405)  |
|                                   | 713-2415                         |
|                                   |                                  |
|                                   | ####### **                       |
|                                   | E-mail**: <alafazia@odmdsas.org> |
+-----------------------------------+----------------------------------+

# Appendix F: Southwest Region NPN/Tribal Representatives

+-----------------------------------+----------------------------------+
| ####### **TEXAS**                 | #### *Cherokee Nation*           |
|                                   |                                  |
| ##### Esther Betts, Behavio       | BJ Boyd, Director Prevention     |
| ral Health Prevention Coordinator | Programs                         |
|                                   |                                  |
| Mental Health & Substance Abuse   | Cherokee Nation Behavorial       |
| Services                          | Health Center                    |
|                                   |                                  |
| Department of State Health        | 1140 Mayberry Dr.                |
| Services                          |                                  |
|                                   | Tahlequah, OK 74464              |
| 1100 W.45^th^ Street              |                                  |
|                                   | \(918\) 458-6285 **Fax:** (918)  |
| Austin, TX 78756-0529             | 458-7601                         |
|                                   |                                  |
| **FED-EX Address:**               | Email: <bj-boyd@cherokee.org>    |
|                                   |                                  |
| 909 W. 45^th^ Street              |                                  |
|                                   |                                  |
| Austin, TX 78751                  |                                  |
|                                   |                                  |
| \(512\) 206-5865 **Fax:** (512)   |                                  |
| 206-4775                          |                                  |
|                                   |                                  |
| **E-mail:**                       |                                  |
| <esther.betts@dshs.state.tx.us>   |                                  |
+-----------------------------------+----------------------------------+

# Appendix G: NPN/Tribal Representative Approval Form

  -----------------------------------------------------------------------
  **APPLICANT'S NAME:**

  -----------------------------------------------------------------------

**TO BE COMPLETED BY YOUR STATE's NPN OR TRIBAL REPRESENTATIVE.**

The above named program is applying to the SWCAPT Regional Service to
Science Academy. In considering the application we would appreciate your
feedback. Since the applicant's application is not considered complete
until we receive your response, an early reply is appreciated.

Please check one of the following:

-   Service to Science would be beneficial to this program

-   Service to Science would not be beneficial to this program at this
    time.

The Southwest CAPT finds additional comments a very helpful guide in the
selection process we appreciate any additional information you would
like to provide.

+-------------+--------------------------------------------------------+
| NPN/Tribal  |                                                        |
| Rep         |                                                        |
| resentative |                                                        |
|             |                                                        |
| Signature:  |                                                        |
+-------------+--------------------------------------------------------+
| State:      |                                                        |
+-------------+--------------------------------------------------------+
| Date:       |                                                        |
+-------------+--------------------------------------------------------+

**Please Return to: LaShonda Williamson at <lwilliamson@ou.edu> or FAX
to: (405) 325-7092**

# Appendix H: Application Checklist

-   Cover Sheet

-   Abstract

-   Program Narrative

    -   Philosophy

    -   Needs Assessment

    -   Population Served

    -   Goals & Objectives

    -   Activities & Strategies

    -   Evaluation (a logic model must accompany this section for
        application to be complete)

    -   Program Management

```{=html}
<!-- -->
```
-   Proof

-   Gather appropriate consent to submit

-   Submit electronically to <lwilliamson@ou.edu> & cc <swpc@ou.edu> or
    mail to:

> CSAP's Southwest CAPT
>
> Attention: LaShonda Williamson
>
> 555 E. Constitution Ave. Ste 144
>
> Norman, OK 73072