**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Substance Abuse and Mental Health Services Administration**

**Center for Substance Abuse Prevention**

**Request for Applications (RFA) No. SP03-007**

**Cooperative Agreements** **to**

**Conduct Targeted Capacity Expansion (TCE) of Ecstasy and Other Club
Drugs Prevention Interventions and/or Infrastructure Development**

**Short Title: Prevention of Ecstasy Abuse**

# Part I- Programmatic Guidance

**Application Receipt Date: July 22, 2003**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Elaine P. Parry Charles G. Curie, M.A., A.C.S.W

Acting Director, Administrator,

Center for Substance Abuse Prevention Substance Abuse and Mental Health

Substance Abuse and Mental Health Services Administration

Services Administration

Date of Issuance: April 2003

Catalog of Federal Domestic Assistance (CFDA) No. 93.243

Authority: Section: 519E of the Public Health Service Act, as amended
and subject to the availability of funds

**Table of Contents**

\[Note to Applicants: To prepare a complete application, "Part II --
General Policies and Procedures Applicable to all SAMHSA Applications
for Discretionary Grants and Cooperative Agreements," must be used in
conjunction with this document, "Part I - Programmatic Guidance."\]

Agency\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...........\...\...\...\...\...\...\...\...\.......\.....
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Purpose of this
Announcement\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......\...\...\...\...\...\...\......
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Who Can
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Application
Kit\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......
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How to Get an Application
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Where to Send the
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Application Due
Date\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\........
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How to Get
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Cooperative
Agreements\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......
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Award
Criteria\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......
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Post Award
Requirements\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\......
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Program
Overview\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.........
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What to Include in Your
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.........
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Face Page

Abstract

Table of Contents

Budget Form

Project Narrative and Supporting Documentation

Appendices

Assurances

Certifications

Disclosure of Lobbying Activities

Checklist

Project Narrative -- Sections A through
D\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\......\.......\....
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Section A: Project Description

Section B: Project Approach

Section C: Project Evaluation

Section D: Project Management and Staffing

SAMHSA Participant Protection and Protection of Human
Subjects....................... 10

Special Considerations and
Requirements\...\...\...\...\...\...\...\...\...\...\...........\...\...\...\...\...\.......\...\.....
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Appendices

Appendix A: Data Reporting Requirements, CSAP GPRA........\.........
.......... 14

Appendix B:
References\...\...\...\..................\.......\...\...\...\...\.............................
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Appendix C:
Glossary\...\...\...\...................\.......\...\...\...\...\...............................
33

Appendix D: Terms and
Conditions...................................................... 35

**[Agency]{.underline}**

Department of Health and Human Services (DHHS), Substance Abuse and
Mental Health Services Administration.

**[Purpose of this Announcement]{.underline}**

The Substance Abuse and Mental Health Services Administration (SAMHSA),
Center for Substance Abuse Prevention is accepting applications for
Fiscal Year 2003 for cooperative agreements to conduct targeted capacity
expansion of ecstasy and other club drug prevention interventions and/or
infrastructure development.

Approximately \$4 million will be available for 14 awards in FY 2003.
The average award will range from \$300,000 to \$350,000 in total costs
(direct and indirect). Cost sharing is not required in this program.
Actual funding levels will depend on the availability of funds.

**Applications with proposed budgets that exceed \$350,000 will be
returned without review.**

Awards may be requested for up to one year. Depending on the
availability of funds, grantees may apply for limited competitive
renewal at the end of year 01 to continue into years 02 and 03.

![](media/image1.wmf){width="9.305555555555556e-2in"
height="9.305555555555556e-2in"}**[Who Can Apply?]{.underline}**

Eligible applicants are public and domestic private non-profit entities
such as:

-   Units of State and local governments

-   Indian tribes and tribal organizations

-   Community-based organizations

-   Managed care and other health care delivery systems

-   Universities and colleges

-   Faith-based organizations and

-   Local law enforcement agencies

-   Current grantees as well as entities that are not current grantees

    **[Application Kit]{.underline}**

    SAMHSA application kits include the following:

    **1. PHS 5161-1 -** *(revised July 2000) **-*** Includes the Face
    Page, Budget forms, Assurances, Certifications and Checklist.

**2. PART I** - of the Program Announcement (PA) or Request for
Applications (RFA) includes instructions for the specific grant or
cooperative agreement application. This document is Part I.

**3. PART II** - of the Program Announcement (PA) or Request for
Applications (RFA)- provides general guidance and policies for SAMHSA
grant applications. The policies in Part II that apply to this program
are listed in this document under "Special Considerations and
Requirements."

**You must use all of the above documents of the kit in completing your
application.**

![](media/image1.wmf){width="9.305555555555556e-2in"
height="9.305555555555556e-2in"}**[How to Get an Application
Kit:]{.underline}**

-   Call: The National Clearing House for Alcohol and Drug Information
    (NCADI) at 1-800-729-6686: TDD: 1-800-487-4889*;* or

-   Download **Part I, Part II and the PHS 5161-1** of the application
    kit from the SAMHSA web site at
    [www.samhsa.gov.](http://www.SAMHSA.gov./) Click on "Grant
    Opportunities" and then "Current Grant Funding Opportunities."

**[Where to Send the Application]{.underline}**

Send the original and 2 copies of your grant application to:

**SAMHSA Programs**

Center for Scientific Review

National Institutes of Health

Suite 1040

6701 Rockledge Drive MSC-7710

Bethesda, MD 20892-7710

\*\*Change the zip code to 20817 if you use express mail or courier
service.

**All applications MUST be sent via a recognized commercial or
governmental carrier. Hand carried applications will not be accepted.
Faxed or e-mailed applications will not be accepted. You will be
notified by letter that your application has been received.**

Be sure to type "SP03-007, Targeted Capacity Expansion of Ecstasy and
Other Club Drugs Prevention Interventions and/or Infrastructure
Development" in Item Number 10 on the face page of the application form.

If you require a phone number for delivery, you may use (301) 435-0715.

**[Application Due Date]{.underline}**

Your application must be [received]{.underline} by July 22, 2003

Applications received after this date must have a proof-of-mailing date
from the carrier before July 15, 2003. Private metered postmarks [are
not]{.underline} acceptable as proof of timely mailing. Late
applications will be returned without review.

**[How to Get Help]{.underline}**

**For questions on program issues, contact:**

Pamela C. Roddy, Ph.D

Project Officer

Center for Substance Abuse Prevention

5600 Fishers Lane, Rockwall II, Suite 1075

Rockville, MD 20857

\(301\) 443***-***1001

E-Mail: <proddy@samhsa.gov>

Soledad Sambrano, PhD

Team Leader

Center for Substance Abuse Prevention

5600 Fishers Lane, Rockwall II, Suite 1075

Rockville, MD 20857

\(301\) 443-7658

E-Mail: <ssambrano@samhsa.gov>

**For questions on grants management issues, contact:**

Stephen Hudak

Grants Management Officer

Division of Grants Management

Substance Abuse and Mental Health Services Administration/OPS

5600 Fishers Lane/ Rockwall II, 6^th^ floor

Rockville, MD 20857

\(301\) 443-9666

shudak@samhsa.gov

**[Cooperative Agreements]{.underline}**

These awards are being made as cooperative agreements because they
require substantial Federal staff involvement.

**Awardees Must:**

-   Comply with the terms of the agreement.

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-   Agree to provide SAMHSA and the Program Coordinating Center (PCC)
    with data required for the Government Performance and Results Act
    (GPRA) and for SAMHSA/CSAP Core Measures, when applicable on a
    quarterly basis.

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-   Participate in PCC cross-site activities.

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-   Work with the PCC by providing data for the preparation of a
    year-end Report to Congress.

    **SAMHSA Staff Will:**

-   Review and provide substantive guidance and technical assistance
    regarding individual awardee designs, selection of measures, and
    analytical plans.

-   Work with the PCC and the awardees using similar programs to
    facilitate cross-site evaluations to build the knowledge base
    related to the programs' effectiveness. Collect, evaluate, report
    and disseminate individual study results.

-   Monitor and review progress of awardees including conducting site
    visits.

-   Participate in PCC meetings, as well as on advisory and other
    groups.

    **The Program Coordinating Center (PCC) that is funded under a
    Contract will:**

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-   Work with the Government Project Officer (GPO) and awardees to
    conduct an evaluation of the ecstasy and other club drugs targeted
    capacity expansion of prevention interventions and/or infrastructure
    development.

-   Prepare a year-end Report to Congress on the results of the targeted
    capacity expansion of prevention interventions and infrastructure
    development. This report should discuss the scope of the problem,
    the state of the art of prevention interventions and infrastructure
    development that can address the problem, and results of the funded
    programs.

-   If individual level data are to be collected, work with the GPO and
    awardees to collect GPRA and SAMHSA/CSAP Core Measures data in a
    data repository; maintain the repository; provide periodic data
    summaries to the GPO and the awardees; and forward data summaries
    and updates to CSAP on a quarterly basis.

-   Provide coordination, technical assistance, support and strategic
    and operational advice to awardees for the cross-site analyses.

-   Set up a new grantee meeting within 90 days of the award.

-   Provide logistics for awardee meetings.

    **[Award Criteria]{.underline}**

    Decisions to fund a grant are based on:

    1\. The strengths and weaknesses of the application as identified by
    the Peer Review Committee and approved by the Center for Substance
    Abuse Prevention National Advisory Council.

    2\. Availability of funds

    3\. In accordance with Section 506 B of the Ecstasy
    Anti-Proliferation Act of 2000, "The administrator will give
    priority in awarding grants under this section to rural and urban
    areas that are experiencing an increase in abuse and addiction to
    3,4- methylenedioxy methamphetamine, related drugs and other club
    drugs."

## Post Award Requirements

1)  Program Reports

    a.  Quarterly reports

    b.  Final report

2)  Final Financial Status reports

3)  Grantees must inform the Project Officer of any planned publications
    or presentations at professional forums based on the grant project.

4)  Grantees must provide information required by SAMHSA to comply with
    the Government Performance and Results Act (GPRA) reporting
    requirements.

    GPRA mandates accountability and performance-based management by
    Federal agencies. The instruments are attached as Appendix A. The
    goal is to focus on results or outcomes in evaluating the
    effectiveness of Federal activities and on measuring progress toward
    achieving national goals and objectives. Pursuant to this, all
    grantees providing direct services for participants aged 12 and
    older must comply with GPRA data collection and reporting
    requirements by using the instruments listed below.

-   GPRA Youth Instrument

-   GPRA Adult Instrument

    In rare instances, it might not be appropriate for a grantee to
    collect GPRA data. In that case, the grantee must discuss the
    feasibility of an exemption with the project officer.

    If grantees wish to measure other domains, they should use the
    SAMHSA/CSAP Core Measures Instrument, if applicable. The use of Core
    Instruments requires a separate program submission-specific
    submission to OMB for review and approval. The measures can be
    obtained from
    [www.PreventionDSS.org](http://www.PreventionDSS.org/).

    Grantees that perform infrastructure development activities will be
    required to provide different data, which may include number and
    types of trainings provided, documentation of improvement in
    prevention capacity, etc. Exact measures will be determined after
    award and discussion with project officers. Depending on the nature
    of these data, there may be a need for OMB clearance

    **[Program Overview]{.underline}**

In support of the authorizing legislation, this targeted capacity
expansion and infrastructure development program addresses the growing
problem of ecstasy and other club drugs abuse and addiction by assisting
localities to conduct targeted capacity expansions of prevention
interventions that are effective and evidence-based and/or
infrastructure development. The goal is to intervene effectively so as
to prevent, reduce or delay the use and/or spread of ecstasy and other
club drugs abuse.

Ecstasy, scientifically known as 3,4-methylenedioxy methamphetamine, is
commonly referred to "E" or MDMA. It is one of a number of dangerous
substances collectively referred to as "club drugs." The name, "club
drugs" derives from the fact that young people who attend "raves" or all
night dance parties at clubs and bars often use these drugs. In addition
to ecstasy, other common substances used in this context include
gamma-hydroxybutyrate (GHB), ketamine, Rohypnol (one of the "date rape"
drugs), and LSD. Ecstasy and other club drug abuse is an extremely
serious and escalating problem. According to the 2000 Monitoring the
Future Study on High School drug use, the percent of 12th graders using
ecstasy rose from 4.0 percent in 1997 to 9.2 percent in 2001 (Johnston
et al., 2001). This increase in use prompted Congress to enact the
Ecstasy Anti-Proliferation Act of 2000, which funds this program.
Contrary to some popular opinion, these drugs are harmful causing both
stimulant and psychedelic effects.

The wide availability of ecstasy and other club drugs at gay bars, sex
clubs and bathhouses is contributing to their increased use. Club drug
use is strongly related to high-risk sexual behavior, especially among
men who have sex with men. Moreover, polydrug use is the norm, with many
of the drugs listed above used together along with alcohol, marijuana
and PCP.

The program will build on the knowledge developed from the past
Community-Initiated Prevention Intervention (CIPI) programs and other
demonstrably effective interventions targeted towards other drugs. This
knowledge concerning effective prevention, early intervention services
and capabilities can inform those efforts and capacity requirements that
will be needed to deal effectively with ecstasy and other club drugs use
and developing a relevant prevention infrastructure.

This TCE program will address these prevention needs by supporting the
targeted capacity expansion of evidence-based and effective prevention
interventions tailored for ecstasy and other club drugs use and/or
infrastructure development. Such projects can include but not be limited
to:

-   Replicating, developing, implementing and/or adapting
    evidence-based, effective prevention interventions.

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-   Conducting school-based programs about the dangers of ecstasy and
    other club drugs that are focused on those districts with high or
    increasing rates of ecstasy and other club drugs abuse and addiction
    and targeted at populations who are most at risk for ecstasy and
    other club drugs abuse.

-   Conducting community-based prevention programs about the dangers of
    ecstasy and other club drugs that are focused on children, youth,
    young adults and parents in the community who are most at risk for
    ecstasy and other club drugs abuse and addiction.

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-   Targeting pilot programs with evaluation components to encourage
    innovation and experimentation with new methodologies.

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-   Training and educating State and local law enforcement officials,
    prevention and education officials, members of community anti-drug
    coalitions and parents on the signs of ecstasy and other club drug
    abuse and addiction and the options for treatment and prevention.

-   Monitoring and evaluating ecstasy and other club drug prevention
    activities, and reporting and disseminating resulting information to
    the public.

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-   Establishing prevention referral and linkage systems to other
    supportive services such as transportation, child-care, counseling
    etc.

-   Conducting outreach strategies to expand prevention
    services/activities to under-served populations residing in rural
    communities, inner cities and Native American reservations.

**[What to Include in Your Application]{.underline}**

In order for your application to be complete, it must include the
following in the order listed. Check off areas as you complete them for
your application.

-   **[1. FACE PAGE]{.underline}**

    Use Standard Form 424, which is part of the PHS 5161-1. See Appendix
    A in Part II of the RFA for instructions. In signing the face page
    of the application, you are agreeing that the information is
    accurate and complete.

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-   **[2. ABSTRACT]{.underline}**

    Your total abstract should not be longer than 35 lines. In the
    [first 5 lines or less]{.underline} of your abstract, write a
    summary of your project that can be used, if your project is funded,
    in publications, reporting to Congress, or press releases. In
    addition, write a 10-line abstract

    For SAMHSA internal reporting purposes.

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-   [**3. TABLE OF CONTENTS**]{.underline}

    Include page numbers for each of the major sections of your
    application [and]{.underline} for each appendix.

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-   **[4. BUDGET FORM]{.underline}**

    Standard Form (SF) 424A, which is part of the PHS 5161-1 is to be
    used for the budget. Fill out sections B, C, and E of the SF 424A.
    Follow instructions in Appendix B of Part II of the RFA.

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-   **[5. PROJECT NARRATIVE AND SUPPORTING DOCUMENTATION]{.underline}**

    **The Project Narrative describes your project. It consists of
    Sections A through D.** These sections may not be longer than 25
    pages. More detailed information about Sections A through D follows
    #10 of this checklist.

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-   **Section A --** Project Description

-   **Section B** -- Project Approach

-   **Section C** -- Project Evaluation

-   **Section D** -- Project Management and Staffing

    **The Supporting Documentation section of your application provides
    additional information necessary for the review of your application.
    This Supporting Documentation should be provided immediately
    following your Project Narrative in Sections E through H.** There
    are no page limits for these sections, except for Section G, the
    Biographical Sketches/Job Descriptions.

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-   **Section E** **-** Literature Citations. This section must contain
    complete citations, including titles, dates, and all authors, for
    any literature you cite in your application.

-   **Section F** **-** Budget Justification, Existing Resources, Other
    Support. You must provide a narrative justification of the items
    included in your proposed budget as well as a description of
    existing resources and other support you expect to receive for the
    proposed project. **(See Part II of the RFA/PA, grant announcement,
    Example A, Justification).**

-   **Section G** - Biographical Sketches and Job Descriptions

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-   Include a biographical sketch for the project director and for other
    key positions. Each sketch should not be longer than **2 pages**. If
    the person has not been hired, include a letter of commitment from
    the individual with a current biographical sketch.

-   Include job descriptions for key personnel. They should not be
    longer than **1 page**.

-   **Sample sketches and job descriptions are listed** **[on page
    22]{.underline}, Item 6 in the Program Narrative section of the PHS
    5161-1.**

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-   **Section H** **--** Protection of Human Subjects, 45 CFR Part 46.
    The elements you need to address in this section are outlined after
    the Project Narrative description in this document.

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-   **[6. APPENDICES 1 THROUGH 4]{.underline}**

-   Use only the appendices listed below.

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-   **Do not** use appendices to extend or replace any of the sections
    of the Project Narrative unless specifically required in this RFA
    (reviewers will not consider them if you do).

-   **Do not** use more than **30** pages (plus all instruments) for the
    appendices.

    **Appendix 1:**

    Letters of Coordination and Support including any Memoranda of
    Understanding (MOU)

    **Appendix 2:**

    Data Collection Instruments and Interview Protocols.

**Appendix 3:**

Copy of Letter(s) to the Single State Agencies (SSA's). Please refer to
Part II of the RFA.

**Appendix 4**

Sample Consent Forms

-   **[7. ASSURANCES]{.underline}**

    Non-Construction Programs. Use Standard form 424B found in PHS
    5161-1.

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-   **[8*.* CERTIFICATIONS]{.underline}**

    Use the \"Certifications\" forms, which can be found in PHS
    5161-1*.* See Part II of the RFA for instructions.

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-   **[9. DISCLOSURE OF LOBBYING ACTIVITIES]{.underline} (See form in
    PHS 5161-1)**

    Appropriated funds, other than for normal and recognized
    executive-legislative relationships, may not be used for lobbying
    the Congress or State legislatures. Federal law prohibits the use of
    appropriated funds for publicity or propaganda purposes or for the
    preparation, distribution, or use of the information designed to
    support or defeat legislation pending before the Congress or State
    legislatures. This includes "grass roots" lobbying, which consists
    of appeals to members of the public suggesting that they contact
    their elected representatives to indicate their support for or
    opposition to pending legislation or to urge those representatives
    to vote in a particular way. (Please read **Part II** of the
    RFA***,*** General Policies and Procedures for all SAMHSA
    applications for additional details.)

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-   **[10. CHECKLIST]{.underline}** (Found in the PHS 5161)

    You must complete the Checklist. See Part II Appendix C of the RFA
    for detailed instructions.

    [**Project** **Narrative **]{.underline}

    **Sections A through D**

    In developing your application, use the instructions below that have
    been tailored to this program. These are to be used in lieu of the
    "Program Narrative" instructions found in the PHS 5161 on page 21.

    **Sections** A **through D are the Project Narrative of your
    application.** These sections describe what you intend to do with
    your project**.** Below you will find detailed information on how to
    respond to Sections A through D. Sections A through D [may
    not]{.underline} be longer than 25 pages.

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-   **Your application will be reviewed and scored against the
    requirements described below for sections A through D*.* These
    sections also function as review criteria.**

-   A peer review committee will assign a point value to your
    application based on how well you address **each** of these
    sections.

-   The number of points after each main heading shows the maximum
    number of points a review committee may assign to that category.

-   Bullet statements do not have points assigned to them; they are
    provided to invite attention to important areas within the
    criterion.

-   Reviewers will also be looking for evidence of cultural competence
    **in each section** of the Project Narrative. Points will be
    assigned based on how well you address cultural competency aspects
    of the review criteria. SAMHSA's guidelines for cultural competence
    are included in Part II of the RFA, Appendix D.

    **Section A:** **Project Description**

    **15 points**

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-   Document the current need for prevention targeted capacity expansion
    or infrastructure development using local incidence and/or
    prevalence data appropriate for the target population in the
    community you propose to influence. Include additional data
    regarding lack of educational programs for persons at risk, training
    programs for professionals, law enforcement personnel and the like.

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-   Describe the target population in terms of number, race, ethnicity,
    age and gender as well as it's risk for ecstasy and other club drugs
    abuse and addiction.

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-   Describe how the proposed targeted capacity expansion prevention
    intervention and/or infrastructure development project will address
    the availability and access to prevention services and/or activities
    in the community.

-   Document the effectiveness of the proposed adopted/adapted
    intervention and how it relates to ecstasy and other club drugs and
    changes that will be made to it to better address these drugs
    through a current literature review or preliminary supporting data,
    and provide a clear rationale for its choice.

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-   Document the decision making process used to select the targeted
    capacity expansion prevention intervention or infrastructure
    development project to be implemented. Specify who and what
    community members and organizations along with their particular
    expertise will participate. List key aspects of the decision making
    process.

    **Section B: Project Approach**

    **30 points**

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-   Describe how the proposed project addresses the purpose of the RFA,
    the number of people to be served and the expected outcomes.

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-   Describe what services/activities comprise the proposed prevention
    targeted capacity expansion and/or infrastructure development
    project. Provide letters of coordination and support and MOUs in
    Appendix 1.

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-   Describe how the proposed targeted capacity expansion of prevention
    interventions and/or infrastructure development project is
    appropriate for the age, gender, sexual orientation and culture of
    the target population.

-   Describe how the project will be implemented.

-   Describe participant outreach, retention and follow-up procedures.

**Section C: Project Evaluation**

**30 points**

-   Describe how the project will be evaluated. CSAP encourages but does
    not require a comparison group or a pre-post design to determine if
    the project addresses the purpose of the RFA. Specify what the
    process and outcome measures will be. Outcome measures can be
    qualitative and/or quantitative measures.

-   All grantees collecting individual services data from participants
    aged 12 and older must use the SAMHSA/CSAP GPRA data collection tool
    to collect entry and exit data with an 80 percent response rate to
    determine outcomes.

-   Grantees, who wish to measure other domains, should use the CSAP
    Core Measures Instrument, if applicable.

-   Describe strategies for data collection and analyses to determine
    whether or not the project addresses the purpose of the RFA.

-   Describe the data management, processing and clean-up, quality
    control and confidentiality procedures.

**Section D: Project Management and Staffing 25 points**

-   Provide a project management implementation plan in table format
    that includes a time line that lists specific activities, completion
    dates and responsible persons.

-   Develop a sustainability plan for securing resources to sustain the
    project once Federal funding ends and document progress made in
    implementing this plan in the quarterly, biannual and year-end
    reports.

-   Describe the capabilities of the organization and collaborating
    agencies with similar projects and populations.

-   Describe the proposed staffing plan and the qualifications and
    relevant experience of the key staff. This experience must pertain
    to substance abuse prevention and related services.

-   Describe the cultural capabilites of the staff to ensure cultural
    competence in communicating with the target populations.

-   Describe the relevant resources such as computer facilities and
    equipment, as well the location/facility in terms of space,
    accessibility (in compliance with the Americans with Disabilities
    Act) and environment.

-   Describe other resources not accounted for in the proposed budget
    but necessary for the project, any plans for securing resources to
    sustain the project once federal funding is terminated, or for
    reducing the project if it is not possible to obtain additional
    resources.

    NOTE: Although the budget for the proposed project is not a review
    criterion, the Review Group will be asked to comment on the
    appropriateness of the budget after the merits of the application
    have been considered.

    **[SAMHSA Participant Protection and]{.underline}** **[Protection of
    Human Subjects Regulations]{.underline}**

    Part II of the PA/RFA provides a description of SAMHSA's Participant
    Protection Requirements and the Protection of Human Subjects
    Regulations (45 CFR 46). The Federal policy for the protection of
    human subjects is stipulated in the Code of Federal Regulations
    (CFR), Title 45, Part 46.

    **[SAMHSA Participant Protection]{.underline}**

For this announcement, all grant applications must adhere to the
following requirements:

You [must]{.underline} address each element regarding participant
protection in your supporting documentation. If any one or all of the
elements is not relevant to your project, you must document the reasons
that the element(s) does not apply.

Each of the following elements [must be discussed]{.underline}:

[Protect Clients and Staff from Potential Risks]{.underline}

-   Identify and describe any foreseeable physical, medical,
    psychological, social, legal, or other risks or adverse affects.

-   Discuss risks that are due either to participation in the project
    itself, or to the evaluation activities.

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-   Describe the procedures that will be followed to minimize or protect
    participants against potential risks, including risks to
    confidentiality.

-   Give plans to provide help if there are adverse effects to
    participants.

-   Where appropriate, describe alternative treatments and procedures
    that may be beneficial to the participants. If you do not decide to
    use these other beneficial treatments, provide the reasons for not
    using them.

    [Fair Selection of Participants]{.underline}

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```
-   Describe the target population(s) for the proposed project. Include
    age, gender, racial/ethnic background and note if the population
    includes homeless youth, foster children, children of substance
    abusers, pregnant women, or other groups.

-   Explain the reasons for including groups of pregnant women,
    children, people with mental disabilities, people in institutions,
    prisoners, or others who are likely to be vulnerable to HIV/AIDS.

-   Explain the reasons for [including or excluding]{.underline}
    participants.

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```
-   Explain how you will recruit and select participants. Identify who
    will select participants.

    [Absence of Coercion]{.underline}

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```
-   Explain if participation in the project is voluntary or required.
    Identify possible reasons why it is required. For example, court
    orders requiring people to participate in a program.

-   If you plan to pay participants, state how participants will be
    awarded money or gifts.

-   State how volunteer participants will be told that they may receive
    services even if they do not complete the study.

    [Data Collection]{.underline}

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<!-- -->
```
-   Identify from whom you will collect data; for example, participants
    themselves, family members, teachers, others. Describe the data
    collection procedure and specify the sources for obtaining data; for
    example, school records, interviews, psychological assessments,
    questionnaires, observation, or other sources. Where data are to be
    collected through observational techniques, questionnaires,
    interviews, or other direct means, describe the data collection
    setting.

-   Identify what type of specimens (e.g., urine, blood) will be used,
    if any. State if the material will be used just for evaluation or if
    other use(s) will be made. Also, if needed, describe how the
    material will be monitored to ensure the safety of participants.

```{=html}
<!-- -->
```
-   Provide in Appendix 2, "Data Collection Instruments/Interview
    Protocols," copies of [all]{.underline} available data collection
    instruments and interview protocols that you plan to use.

    [Privacy and Confidentiality:]{.underline}

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<!-- -->
```
-   Explain how you will ensure privacy and confidentiality. Include who
    will collect data and how it will be collected.

-   Describe:

```{=html}
<!-- -->
```
-   How you will use data collection instruments.

-   Where data will be stored.

-   Who will or will not have access to information.

-   How the identity of participants will be kept private. For example,
    through the use of a coding system on data records, limiting access
    to records, or storing identifiers separately from data.

    **NOTE:** If applicable, grantees must agree to maintain the
    confidentiality of alcohol and drug abuse client records according
    to the provisions of **Title 42 of the Code of Federal Regulations,
    Part II.**

    [Adequate Consent Procedures:]{.underline}

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<!-- -->
```
-   List what information will be given to people who participate in the
    project. Include the type and purpose of their participation.
    Include how the data will be used and how you will keep the data
    private.

-   State:

```{=html}
<!-- -->
```
-   Whether or not their participation is voluntary;

-   Their right to leave the project at any time without problems;

-   Possible risks from participation in the project;

-   Plans to protect clients from these risks.

```{=html}
<!-- -->
```
-   Explain how you will get consent for youth, the elderly, and people
    with limited reading skills, and people who do not use English as
    their first language.

    NOTE: If the project poses potential physical, medical,
    psychological, legal, social or other risks, you **must** get
    [written]{.underline} informed consent.

```{=html}
<!-- -->
```
-   Indicate if you will get informed consent from participants or from
    their parents or legal guardians. Describe how the consent will be
    documented. For example: Will you read the consent forms? Will you
    ask prospective participants questions to be sure they understand
    the forms? Will you give them copies of what they sign?

-   Include sample consent forms in your Appendix 4 titled "Sample
    Consent Forms." If needed, give English translations.

    NOTE: Never imply that the participant waives or appears to waive
    any legal rights, may not end involvement with the project, or
    releases your project or its agents from liability for negligence.

```{=html}
<!-- -->
```
-   Describe if separate consents will be obtained for different stages
    or parts of the project. For example, will they be needed for both
    participant protection in treatment intervention and for the
    collection and use of data.

-   Additionally, if other consents (e.g., consents to release
    information to others or gather information from others) will be
    used in your project, provide a description of the consents. Will
    individuals who do not consent to having individually identifiable
    data collected for evaluation purposes be allowed to participate in
    the project?

    [Risk/Benefit Discussion:]{.underline}

    Discuss why the risks are reasonable compared to expected benefits
    and importance of the knowledge from the project.

    **[Protection of Human Subjects Regulations]{.underline}**

All grant programs collecting individual level data and administering
GPRA measures at pre‑ and post‑intervention MUST adhere to Protection of
Human Subjects Regulations (45 CFR 46) and MUST propose plans for
implementing these regulations including obtaining Institutional Review
Board (IRB) approval. IRB approval is not required at the time of grant
award, however the process for IRB approval should be discussed fully in
the grant application and obtained before the recruitment of
participants. As a condition of grant award, funds will be restricted
for recruitment of participants until a grantee submits an approved IRB
plan to the CSAP Project Officer.

**You must refer to Part II** of the RFA/PA, SAMHSA Participant
Protection and Protection of Human Subjects for additional information
regarding confidentiality and the requirements of 45 CFR Part 46,
Protection of Human Subjects, including Assurance of Compliance and
documentation of Institutional Review Board (IRB) approvals.

**[Special Considerations and Requirements]{.underline}**

SAMHSA's policies, special considerations and requirements related to
grants and cooperative agreements are found in **Part II** of the
RFA/PA. The policies and special considerations that apply to this
program are:

-   Population Inclusion Requirement

-   Government Performance Monitoring

-   Healthy People 2000

-   Consumer Bill of Rights and Responsibilities

-   Promoting Nonuse of Tobacco

-   Supplantation of Existing Funds

-   Letter of Intent

-   Coordination with Other Federal/Non Federal Programs (Include
    response in Appendix 1 of your Application)

-   Single State Agency Coordination

-   Intergovernmental Review (E.O. 12372)

-   Public Health System Reporting Requirements

-   Confidentiality/SAMHSA Participant and Human Subject Protection

    (Note: Provide your responses to Participant Protection under
    Supporting Documentation (Section I) in your Application. Provide
    your response to Data Collection Initiatives/Interview Protocols
    (Item 4 of Participant Protection) in Appendix 2 of your
    Application; and Sample Consent Forms \[Item 6 of Participant
    Protection\] in Appendix 3 of your Application.)

#### Appendix A: Data Reporting Requirements

Ecstasy and Other Club Drug awardees who plan on collecting individual
level data will agree to provide data responding to the Government
Performance and Results Act of 1993 (GPRA).

##### CSAP's GPRA Strategy 

The Government Performance and Results Act of 1993 (Public Law-103-62)
requires all federal departments and agencies to develop strategic plans
that specify what they will accomplish over a three- to five-year
period, to annually set performance targets related to their strategic
plan, and to annually report the degree to which the targets set in the
previous year were met. In addition, agencies are expected to regularly
conduct evaluations of their programs and to use the results of those
evaluations to "explain" their success and failures based on the
performance monitoring data. While the language of the statute talks
about separate Annual Performance Plans and Annual Performance Reports,
ASMB/HHS has chosen to incorporate the elements of the annual reports
into the annual President's Budget and supporting documents.

The GPRA Measures relevant to the Ecstasy and Other Club Drugs program
are as follows:

> 1\. Decrease past month methampehtamine and inhalant as well as other
> substance use by youth 12 and older and by adults 18 and older.
>
> 2\. Increase negative attitudes about methamphetamine and inhalant as
> well as other substance use by youth 12 and older and by adults 18 and
> older.

CSAP's GPRA Client Outcome Measures for Discretionary Programs (commonly
referred to as the GPRA "Cross Cutting Tool") must be used as part of
this important program-level reporting process.

**Note: This document is contained in the kit that accompanies this
grant announcement, and may also be accessed through CSAP's Prevention
Decision Support System, located on the Web Site
[http://preventiondss.samhsa.gov](http://preventiondss.samhsa.gov/).**
**Click on the "Search" link at the top of the page. Type "GPRA
2003-2005" in the Search Field. Check the radio button, "Find matches
containing all these words." Click the button "Search the PreventionDSS
Portal." Click on the "GPRA 2003-2005" document link. View a PDF example
of the GPRA evaluation instrument that CSAP and other federal agencies
use to collect certain basic information about prevention activities
funded by the federal block grants and other funding mechanisms.**

**[CSAP's Core Outcome Measures]{.underline}**

If awardees are collecting individual level data, they may also use
CSAP's Core Outcome Measures for the data collection and evaluation as
per OMB approval 0930-0230.

The CSAP Core Outcome Measures relevant to the Ecstasy and Other Club
Drugs Program pertain to the individual, family and community domains.

**The CSAP Core Measures Initiative may be accessed through CSAP's
Prevention Decision Support System, located on the website** Go to
preventiondss.org; Scroll down to "Links to More Resources\...."; Click
on GO; Scroll down to "CSAP Core Outcome Measures Initiative"; Click on
"CSAP's Core Outcome Measures"; Click "Here to Continue"; Click on "CMI
Viewer"; that last click will give you access to each of the domains,
constructs and recommended instruments in the Core Measures.

### [Data Access, Sharing and Publication]{.underline}

45 C.F.R. 74.36(a) provides that the recipient may copyright any work
that is subject to copyright and was developed under a grant. SAMHSA
reserves a royalty-free, nonexclusive and irrevocable right to publish
or otherwise use the work under a grant. In this regard, SAMHSA plans to
us\\\*\--e the data under the grant and to publish the results of the
data. Study sites are required to share their data and associated data
documentation as soon as the data are cleaned, coded, and ready for
analyses by SAMHSA/CSAP, including the relevant Program Coordinating
Centers (PCCs) and CSAP's Data Coordinating Center (DCC). These data
will be used to perform cross-site (PCC) and cross-program (DCC)
analyses.

The specific, common data to be submitted to the PCC\'s and DCC will be
communicated shortly after award and, where applicable, be determined by
consensus of the program's steering committee. The data will be
submitted according to an agreed-upon schedule and will include, at a
minimum, data to meet programmatic and CSAP GPRA requirements (including
demographics and relevant intervention characteristics. If no steering
committee exists, common data requirements will be determined as defined
by the individual program. Data typically are submitted by grantees to
the PCC who will then forward copies to the DCC. Where no PCC exists,
data will be forwarded to the DCC by CSAP program staff.

Those entities (e.g., the PCC, the DCC) that will have responsibilities
for and access to the data will strictly follow all regulations and
protocols concerning protection of human subjects, confidentiality, and
privacy. All steering committee agreements (e.g. publication policies,
guidelines about sensitivity to cultural issues) will be honored.

Form Approved

OMB No. 0930-0208

Expiration Date 12/31/2005

**CSAP GPRA Participant Outcome**

**Measures for Discretionary Programs**

**ADULTS**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response if all items are asked of a
participant; to the extent that providers already obtain much of this
information as part of their ongoing participant intake or follow-up,
less time will be required. Send comments regarding this burden estimate
or any other aspect of this collection of information to SAMHSA Reports
Clearance Officer, Room 16-105, 5600 Fishers Lane, Rockville, MD 20857.
An agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently
valid OMB control number. The control number for this project is
0930-0208.

**RECORD MANAGEMENT**

**Participant ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Contract/Grant ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Grant Year** \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

> Year

**Interview Date** \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Interview Type**

1\. Pre-Test 2. Post-Test 3. 6-Month Follow-up

**A. DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)**

**1. Gender**

>  Male
>
> Female

**2. Are you Hispanic or Latino?**

> Yes No

**3. What is your race? (Select one or more)**

> Black or African American Alaska Native
>
> Asian White
>
> American Indian Other (specify)\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Native Hawaiian or Other **\
> **Pacific Islander

**4. What is your date of birth?** \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

> Month / Day / Year

**B. DRUG AND ALCOHOL USE**

+---------------------------------------------------------------------+---+
| 1.  **What is your best estimate of the number of days you used     |   |
|     chewing tobacco during the past 30 days?**                      |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 2.  **What is your best estimate of the number of days you smoked   |   |
|     all or part of a cigarette during the past 30 days?**           |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 3.  **What is your best estimate of the number of days you drank    | [ |
|     alcohol during the past 30 days?**                              | ] |
|                                                                     | { |
| > 0 0 days                                                          | . |
| >                                                                   | m |
| > 1 1 or 2 days                                                     | a |
| >                                                                   | r |
| > 2 3 to 5 days                                                     | k |
| >                                                                   | } |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
| >                                                                   |   |
| > []{.mark}                                                         |   |
+---------------------------------------------------------------------+---+
| 4.  **What is your best estimate of the number of days you used     |   |
|     marijuana or hashish during the past 30 days?**                 |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 5.  **What is your best estimate of the number of days you used     |   |
|     cocaine during the past 30 days?**                              |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 6.  **What is your best estimate of the number of days you used     |   |
|     "crack" during the past 30 days?**                              |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 7.  **What is your best estimate of the number of days you used any |   |
|     inhalant for kicks or to get high during the past 30 days?**    |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 8.  **What is your best estimate of the number of days you used     |   |
|     heroin during the past 30 days?**                               |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 9.  **What is your best estimate of the number of days you used     | [ |
|     hallucinogens during the past 30 days?**                        | ] |
|                                                                     | { |
| > 0 0 days                                                          | . |
| >                                                                   | m |
| > 1 1 or 2 days                                                     | a |
| >                                                                   | r |
| > 2 3 to 5 days                                                     | k |
| >                                                                   | } |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| **10. How old were you the [first time]{.underline} you smoked part |   |
| or all of a cigarette?**                                            |   |
|                                                                     |   |
| > years old If never smoked part or all of a cigarette please mark  |   |
| > the box.                                                          |   |
+---------------------------------------------------------------------+---+
| **11. Think about the [first time]{.underline} you had a drink of   |   |
| an alcoholic beverage. How old were you the first time you had a    |   |
| drink of an alcoholic beverage? Please do not include any time when |   |
| you only had a sip or two from a drink.**                           |   |
|                                                                     |   |
| > years old If never had a drink of an alcoholic beverage please    |   |
| > mark the box.                                                     |   |
+---------------------------------------------------------------------+---+
| **12. How old were you the [first time]{.underline} you used        |   |
| marijuana or hashish?**                                             |   |
|                                                                     |   |
| > years old If never used marijuana or hashish please mark the box. |   |
+---------------------------------------------------------------------+---+
| **13. How old were you the [first time]{.underline} you used any    |   |
| other illegal drugs?**                                              |   |
|                                                                     |   |
| years old If never used any illegal drugs please mark the box.      |   |
+---------------------------------------------------------------------+---+
|                                                                     |   |
+---------------------------------------------------------------------+---+

**D. EDUCATION, EMPLOYMENT, AND INCOME**

**1. What is the highest level of education you have finished, whether
or not you received a degree? \[01=1st grade, 12=12th grade, 13=college
freshman, 16=college completion\]**

\|\_\_\_\_\|\_\_\_\_\| level in years

> **1a. If less than 12 years of education, do you have a GED (General
> Equivalency Diploma)?**
>
> Yes No

**G. ATTITUDES AND BELIEFS**

**1. How much do people risk harming themselves physically and in other
ways when they smoke one or more packs of cigarettes per day?**

No risk

Slight risk

Moderate risk

Great risk

**2. How much do people risk harming themselves physically and in other
ways when they smoke marijuana once a month?**

No risk

Slight risk

Moderate risk

Great risk

3.  **How much do people risk harming themselves physically and in other
    ways when they:**

**a. Have four or five drinks of an alcoholic beverage nearly every
day?**

No risk

Slight risk

Moderate risk

Great risk

**b. Have five or more drinks of an alcoholic beverage once or twice a
week?**

No risk

Slight risk

Moderate risk

Great risk

4.  **How do you feel about adults smoking one or more packs of
    cigarettes per day?**

> Neither approve nor disapprove

Somewhat disapprove

Strongly disapprove

5.  **How do you feel about adults trying marijuana or hashish once or
    twice?**

> Neither approve nor disapprove

Somewhat disapprove

Strongly disapprove

6.  **How do you feel about adults having one or two drinks of an
    alcoholic beverage nearly every day?**

> Neither approve nor disapprove

Somewhat disapprove

Strongly disapprove

7.  **How do you feel about adults driving a car after having one or two
    drinks of an alcoholic beverage?**

> Neither approve nor disapprove

Somewhat disapprove

Strongly disapprove

Form Approved

OMB No. 0930-0208

Expiration Date 12/31/2005

**CSAP GPRA Participant Outcome**

**Measures for Discretionary Programs**

**YOUTH - Age 12 to 17 Years**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response if all items are asked of a
participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or
follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information to
SAMHSA Reports Clearance Officer, Room 16-105, 5600 Fishers Lane,
Rockville, MD 20857. An agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it
displays a currently valid OMB control number. The control number for
this project is 0930-0208.

**RECORD MANAGEMENT**

**Participant ID
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Contract/Grant ID
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Grant Year \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

> **Year**

**Interview Date \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Interview Type**

> 1\. Pre-Test 2. Post-Test 3. 6-Month Follow-up

**A. DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)**

**1. Gender**

>  Male
>
> Female

**2. Are you Hispanic or Latino?**

> Yes No

**3. What is your race? (Select one or more)**

> Black or African American Alaska Native
>
> Asian White
>
> American Indian Other (specify)\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Native Hawaiian or Other\
> Pacific Islander

**4. What is your date of birth?** \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

> Month / Day / Year

**B. DRUG AND ALCOHOL USE**

**1. How frequently have you smoked cigarettes during the past 30
days?**

> 1 Not at all
>
> 2 Less than one cigarette per day
>
> 3 One to five cigarettes per day
>
> 4 About one-half pack per day
>
> 5 About one pack per day
>
> 6 About one and one-half packs per day
>
> 7 Two packs or more per day

**2. How often have you taken smokeless tobacco during the past 30
days?**

> 1 Not at all
>
> 2 Once or twice
>
> 3 Once to twice per week
>
> 4 Three to five times per week
>
> 5 About once a day
>
> 6 More than once a day

**3. To be more precise, during the past 30 days about how many
cigarettes have you smoked per day?**

> 1 None
>
> 2 Less than 1 per day
>
> 3 1 to 2
>
> 4 3 to 7
>
> 5 8 to 12
>
> 6 13 to 17
>
> 7 18 to 22
>
> 8 23 to 27
>
> 9 28 to 32
>
> 10 33 to 37
>
> 11 38 or more

**Alcoholic beverages include beer, wine, wine coolers, and liquor.**

4.  **On how many occasions during the last 30 days have you had
    alcoholic beverages to drink (more than just a few sips)?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

5.  **On how many occasions during the last 30 days (if any) have you
    been drunk or very high from drinking alcoholic beverages?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

6.  **On how many occasions during the last 30 days (if any) have you
    used marijuana (grass, pot) or hashish (hash, hash oil)?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

7.  **During the LAST MONTH, about how many marijuana cigarettes
    (joints, reefers), or the equivalent, did you smoke a day, on the
    average? (If you shared them with other people, count only the
    amount YOU smoked).**

> 1 None
>
> 2 Less than 1 a day
>
> 3 1 a day
>
> 4 2 to 3 a day
>
> 5 4 to 6 a day
>
> 6 7 to 10 a day
>
> 7 11 or more a day

8.  **On how many occasions during the last 30 days (if any) have you
    sniffed glue, or breathed the contents of aerosol spray cans, or
    inhaled any other gases or sprays in order to get high?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

9.  **On how many occasions (if any) during the last 30 days have you
    taken LSD ('acid')?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

**Amphetamines are sometimes called: uppers, ups, speed, bennies,
dexies, pep pills, diet pills, meth or crystal meth. They include the
following drugs: Benzedrine, Dexedrine, Methedrine, Ritalin, Preludin,
Dexamyl, and Methamphetamine.**

10. **On how many occasions (if any) during the last 30 days have you
    taken amphetamines on your own that is, without a doctor telling you
    to take them?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

11. **On how many occasions (if any) during the last 30 days have you
    taken 'crack' (cocaine in chunk or rock form)?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

12. **On how many occasions (if any) during the last 30 days have you
    taken cocaine in any other form (like cocaine powder)?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

13. **Tranquilizers are sometimes prescribed by doctors to calm people
    down, quiet their nerves, or relax their muscles. Librium, Valium,
    and Miltown are all tranquilizers. On how many occasions (if any)
    have you taken tranquilizers on your own that is, without a doctor
    telling you to take them\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions

7.  40 or more occasions

**14. Barbiturates are sometimes prescribed by doctors to help people
relax or get to sleep. They are sometimes called downs, downers,
goofballs, yellows, reds, blues, rainbows. On how many occasions (if
any) have you taken barbiturates on your own that is, without a doctor
telling you to take them\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

**15. On how many occasions (if any) have you smoked (or inhaled the
fumes of) crystal meth ('ice')\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

16. **Amphetamines have been prescribed by doctors to help people lose
    weight or to give people more energy. They are sometimes called
    uppers, ups, speed, bennies, dexies, pep pills, and diet pills.
    Drugstores are not supposed to sell them without a prescription from
    a doctor. Amphetamines do NOT include any non-prescription drugs,
    such as over-the-counter diet pills (like Dexatrim) or stay-awake
    pills (like No-Doz), or any mail-order drugs. On how many occasions
    (if any) have you taken amphetamines on your own that is, without a
    doctor telling you to take them\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

17. **On how many occasions (if any) have you used heroin\...during the
    last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

18. **There are a number of narcotics other than heroin, such as
    methadone, opium, morphine, codeine, demerol, paregoric, talwin, and
    laudanum. They are sometimes prescribed by doctors. On how many
    occasions (if any) have you taken narcotics other than heroin on
    your own that is, without a doctor telling you to take
    them\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

19. **On how many occasions (if any) have you used MDMA ('ecstasy')
    during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

20. **On how many occasions (if any) have you used Rohypnol ('rophies,'
    'roofies') during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

21. **During the last 30 days, on how many occasions (if any) have you
    used GHB ('liquid G,' 'grievous bodily harm')?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

22. **During the last 30 days, on how many occasions (if any) have you
    used Ketamine ('special K,' 'super K')?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

**23. On how many occasions (if any) in your lifetime have you had an
alcoholic beverage-more than just a few sips?**

Never

1 to 2

3 to 5

6 to 9

10 to 19

20 to 39

40 or more

**24. How old were you the [first time]{.underline} you smoked part or
all of a cigarette?**

> years old If you never smoked part or all of a cigarette please mark
> the box.

**25. Think about the [first time]{.underline} you had a drink of an
alcoholic beverage. How old were you the first time you had a drink of
an alcoholic beverage? Please do not include any time when you only had
a sip or two from a drink.**

years old If never had a drink of an alcoholic beverage please mark the
box.

**26. How old were you the [first time]{.underline} you used marijuana
or hashish?**

> years old If never used marijuana or hashish please mark the box.

**27. How old were you the [first time]{.underline} you used any other
illegal drugs?**

> years old If never used any illegal drugs please mark the box.

**D. EDUCATION, EMPLOYMENT, AND INCOME**

**1. What is the highest level of education you have finished, whether
or not you received a degree? \[01=1st grade, 12=12th grade, 13=college
freshman, 16=college completion\]**

\|\_\_\_\_\|\_\_\_\_\| level in years

**G. ATTITUDES AND BELIEFS**

1.  **It is clear to my friends that I am committed to living a
    drug-free life.**

False

Maybe

True

2.  **I have made a final decision to stay away from marijuana.**

False

Maybe

True

3.  **I have decided that I will smoke cigarettes.**

False

Maybe

True

4.  **I plan to get drunk sometime in the next year.**

False

Maybe

True

**5. How much do you think people risk harming themselves (physically or
in other ways) if they smoke one or more packs of cigarettes per day?**

> No risk
>
> Slight risk
>
> Moderate risk
>
>  Great risk

Can't say/Drug unfamiliar

**6. How much do you think people risk harming themselves (physically or
in other ways) if they try marijuana once or twice?**

>  No risk
>
> Slight risk
>
>  Moderate risk
>
>  Great risk

Can't say/Drug unfamiliar

**7. How much do you think people risk harming themselves (physically or
in other ways) if they smoke marijuana regularly?**

> No risk
>
> Slight risk
>
>  Moderate risk
>
>  Great risk

Can't say/Drug unfamiliar

**8. How much do you think people risk harming themselves (physically or
in other ways) if they take one or two drinks nearly every day?**

> No risk
>
>  Slight risk
>
>  Moderate risk
>
>  Great risk

Can't say/Drug unfamiliar

**9. How much do you think people risk harming themselves (physically or
in other ways) if they have five or more drinks once or twice each
weekend?**

>  No risk
>
> Slight risk
>
>  Moderate risk
>
>  Great risk

Can't say/Drug unfamiliar

**10. How wrong do you think it is for someone your age to drink beer,
wine or hard liquor (for example, vodka, whiskey or gin) regularly?**

> Very wrong
>
> Wrong
>
> A little bit wrong
>
> Not wrong at all

11. **How wrong do you think it is for someone your age to smoke
    cigarettes?**

> Very wrong
>
> Wrong
>
> A little bit wrong
>
> Not wrong at all

12. **How wrong do you think it is for someone your age to smoke
    marijuana?**

> Very wrong
>
> Wrong
>
> A little bit wrong
>
> Not wrong at all

13. **How wrong do you think it is for someone your age to use LSD,
    cocaine, amphetamines or another illegal drug?**

> Very wrong
>
> Wrong
>
> A little bit wrong
>
> Not wrong at all

# Appendix B: References

1\. Johnston, L.D., O'Malley, P.M. and Bachman, J.G. (2001) Rise in
ecstasy use among American teens begins to slow. University of Michigan
News and Information Services: Ann Arbor, MI (on-line) Available at
[www.monitoring](http://www.monitoring/)thefuture.org.

2\. Mathias, R. and Zickler, P. (2001) NIDA Conference Highlights
Scientific Findings on MDMA/Ecstasy. NIDA Notes 19. 1-7.cNIDA Research
Report Series: Methamphetamine Abuse and Addiction
at.[www.drugabuse.gov/ResearchReports/methamph/methamph2.html.]{.underline}

3\. NIDA InfoFacts at [www.drugabuse.gov](http://www.drugabuse.gov/).

**Appendix C Glossary**

Cultural Competence - The capacity of individuals to incorporate
ethnic/cultural considerations into all aspects of their work relative
to substance abuse prevention and reduction. Cultural competence is
maximized with implementer/client involvement in all phases of the
implementation process, as well as in the interpretation of outcomes
(Achieving Outcomes, 12/01).

Cultural Competence Promotion - Educated interventions to develop
capacity for culturally competent knowledge, attitudes, and behaviors.
Typically they involve how to: avoid use of stereotypes and biases,
identify positive characteristics of a particular group, increase
readiness to take into account cultural differences, and use of language
and terminology that will best convey culturally sensitive prevention
messages to a particular group. (CSAP has sponsored the development of
prevention training for various racial/ethnic minority groups. See
<http://ncadi.samhsa.gov/initiatives>, go to "CSAP Training Library."

Cultural Diversity - Differences in race, ethnicity, language,
nationality, or religion among various groups within a community,
organization, or nation.

Cultural Sensitivity - The ability to recognize and demonstrate an
understanding of cultural differences (Achieving Outcomes, 12/01).

Culture - The values, traditions, norms, customs, arts, history,
folklore, and institutions that a group of people who are unified by
race, ethnicity, language, nationality, or religion, share.

Effective Intervention - One that has published references that are
cited which document its effectiveness. These references can include
both peer and non-peer reviewed journals. If the selected intervention
results have not yet been published, the applicant must justify its
effectiveness in sufficient detail to convince the reviewers that it has
empirical support. Other definitions of effective programs are provided
in the [Science-Based Prevention Programs and Principles
2002]{.underline}. DHHS Publication No. (SMA) 03-3764. Simply citing an
intervention as "exemplary or "model" is not sufficient, these citations
must be supported by empirical evidence justifying the intervention's
effectiveness.

Gender-specific substance abuse prevention interventions - Programmatic
strategies and activities designed to prevent substance abuse among
either females or males by addressing the risk and protective factors
for substance abuse which are specific to females or males. These
interventions should be based upon gender-specific theoretical models
and should take into account the research literature on gender
differences in risk factors and protective factors, in the relative
importance of these factors, and in the consequences of substance use.

Substance abuse prevention theories, models, and programs to serve both
females and males have been (a) traditional or generic, (b)
gender-informed, or (c) gender-specific. In traditional or generic
programs, boys and girls get similar interventions, but gender-specific
differences in outcomes may be explored. In gender-informed programs,
activities based on more traditional theories or models may be adapted
to take into account research on effectiveness of different strategies
for girls or boys. For example, the mode of presentation, setting, or
sequencing of topics, etc. may be adjusted. In gender-specific programs,
the theoretical underpinnings of programmatic activities take into
account critical issues such as gender-role socialization and
gender-role development. For girls, other important issues also include
their tendency toward internalization, their strong relationship
orientation, and power inequities in intimate relationships.

Science-Based Prevention - \"Science-based\" refers to a process in
which experts use commonly agreed-upon criteria for rating research
interventions and come to a consensus that evaluation research findings
are credible and can be substantiated. From this process, a set of
effective principles, strategies, and model programs can be derived to
guide prevention efforts. This process is sometimes referred to as
research- or evidence-based. Experts analyze programs for credibility,
utility, and generalizability. Credibility refers to the level of
certainty concerning the cause and effect relationship of program to
outcomes. Utility refers to the extent to which the findings can be used
to improve programming, explain program effects or guide future studies.
Generalizability refers to the extent to which findings from one site
can be applied to other settings and populations. Lists of science-based
programs can be found at
[www.modelprograms.samhsa.gov](http://www.modelprograms.samhsa.gov/).

Science-Based Program - In CSAP\'s terminology, a program that is
theory-driven, has activities related to theory, and has been reasonably
well implemented and well evaluated ( [Science-Based Prevention Programs
and Principles 2002]{.underline}. DHHS Publication No. (SMA) 03-3764)

**Appendix D**

**[Terms & Conditions; RFP; RFA language]{.underline}**

45 C.F.R. 74.36(a) provides that the recipient may copyright any work
that is subject to copyright and was developed under a grant. SAMHSA
reserves a royalty-free, nonexclusive and irrevocable right to publish
or otherwise use the work under a grant. In this regard, SAMHSA plans to
use the data under the grant and to publish the results of the data.
Study sites are required to share their data and associated data
documentation as soon as the data are cleaned, coded, and ready for
analyses by SAMHSA/CSAP, including the relevant Program Coordinating
Centers (PCCs) and CSAP's Data Coordinating Center (DCC). These data
will be used to perform cross-site (PCC) and cross-program (DCC)
analyses.

The specific, common data to be submitted to the PCCs and DCC will be
communicated shortly after award and, where applicable, be determined by
consensus of the program's steering committee. The data will be
submitted according to an agreed-upon schedule and will include, at a
minimum, data to meet programmatic and CSAP GPRA requirements (including
demographics and relevant intervention characteristics) and any other
core measures deemed appropriate by the steering committee and/or
necessary to address ONDCP's Performance Measures of Effectiveness and
Healthy People 2010. If no steering committee exists, common data
requirements will be determined as defined by the individual program.
Data typically are submitted by grantees to the PCC who will then
forward copies to the DCC. Where no PCC exists, data will be forwarded
to the DCC by CSAP program staff.

Those entities (e.g., the PCC, the DCC) that will have responsibilities
for and access to the data will strictly follow all regulations and
protocols concerning protection of human subjects, confidentiality, and
privacy. All steering committee agreements, e.g., publication policies,
guidelines about sensitivity to cultural issues, will be honored.

[REVIEW CRITERIA FOR RFAs]{.underline}

The extent to which the proposed project can supply the necessary agency
GPRA data and other data (e.g. HP2010, ONDCP PMEs) on the project's
performance. This would also include core data for cross-site
evaluations, which are determined post-award by CSAP, grantees and other
specified representatives.