Number range CHAPTER

> OMB No. 0930-0080
>
> Approval Expires: 08-31-2007

**FINAL**

**UNIFORM APPLICATION**

**FY 2005**

**SUBSTANCE ABUSE PREVENTION AND TREATMENT**

**BLOCK GRANT**

**42 U.S.C. 300x-21 through 300x-64**

### Substance Abuse and Mental Health Services Administration

**Center for Substance Abuse Treatment**

**Center of Substance Abuse Prevention**

**INTRODUCTION**

The SAPT Block Grant application format provides the means for States to
comply with the reporting provisions of the Public Health Service Act
(42 USC 300x-21-64), as implemented by the Interim Final Rule (45 CFR
Part 96, part XI). With regard to the requirements for Goal 8, the
Annual Synar Report format provides the means for States to comply with
the reporting provisions of the Synar Amendment (section 1926 of the
Public Health Service Act), as implemented by the Tobacco Regulation for
the SAPT Block Grant (45 CFR Part 96, part IV).

Public reporting burden for this collection of information is estimated
to average 470 hours per response for sections I-III, 40 hours per
response for Section IV-A and 56 hours per response for Section IV-B,
including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to SAMHSA Reports
Clearance Officer; Paperwork Reduction Project (OMB No. 0930-0080); 1
Choke Cherry Road, Room 7-1042, Rockville, Maryland 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 OMB control number for this project is OMB No.
0930-0080.

**How the application helps the Substance Abuse and Mental Health
Services Administration**

Part of the mission of the Center for Substance Abuse Treatment (CSAT)
and the Center for Substance Abuse Prevention (CSAP) is to assist
States[^1] and communities to improve activities and services provided
with funds from the Substance Abuse Prevention and Treatment Block Grant
(SAPTBG). One strategy CSAT is using to promote increased State
accountability for the management of block grant funds is the uniform
application. In accordance with the block grant regulations, it asks
States to provide detailed data on expenditures of the FY 2002 SAPT
Block Grant (and intended use of the FY 2005 SAPT Block Grant) and from
State and local government funds. Another strategy is the State Systems
Development Program, an enhanced technical assistance program involving
conferences and workshops, development of training materials and
knowledge transfer manuals, and on-site consultation.

**How the application can help States**

The information gathered for the application can help States describe
and analyze sub-State needs. This data can also be used to report to the
State legislature and other State and local organizations. Aggregated
together, statistical data from States' applications can demonstrate to
Congress the magnitude of the national substance abuse problem. This
information will also provide Congress with a better understanding of
funding needs.

**Where and when to submit the application**

Submit one signed original of the Assurance and Certifications by
October 1, 2004 to:

Ms. LouEllen M. Rice, Grants Management Officer

Substance Abuse and Mental Health Services Administration

Office of Program Services

Division of Grants Management

**Regular Mail** **Overnight mail**:

1 Choke Cherry Road, Room 7-1091 1 Choke Cherry Road, Room 7-1091

Rockville, Maryland 20857 Rockville, Maryland 20850

**Overview of the application**

The application has four sections. It covers the SAPT Block Grant for
the prevention and treatment of substance abuse. Some sections require
the completion of standard forms.

+------------+------------------------------------------+--------------+
| *          | **Contents**                             | **Forms**    |
| *Section** |                                          |              |
+------------+------------------------------------------+--------------+
| #          | Identifying information, Table of        | Forms 1, 2,  |
|  Section I | Contents, and Funding                    | 3            |
|            | Agreements/Certifications                |              |
+------------+------------------------------------------+--------------+
| **Section  | Annual Report -- Actual use of FY 2002   | Form 4, Form |
| II**       | SAPT Block Grant Funds. Narrative: FY    | 6, 6A, Form  |
|            | 2002 Annual Report, FY 2004 Progress     | 7A, Form 7B, |
|            | Report, FY 2005 Intended Use.            | and Tables I |
|            |                                          | through IV   |
|            | Attachments -- Special requirements and  |              |
|            | waivers                                  |              |
+------------+------------------------------------------+--------------+
| **Section  | State Plan -- Intended use of FY 2005    | Forms 8, 9,  |
| III**      | SAPT Block Grant Funds                   | 11,12        |
+------------+------------------------------------------+--------------+
| **Section  | Voluntary Treatment Performance Measures | Forms T1-T8  |
| IV A**     |                                          |              |
+------------+------------------------------------------+--------------+
| **Section  | Voluntary Prevention Performance         | Forms P1-P6  |
| IV B**     | Measures                                 |              |
+------------+------------------------------------------+--------------+

There are detailed instructions for each section and each form. All
States must use this format. The structure of the application cannot be
changed. It must be organized according to the Table of Contents (Form
2) that serves as a checklist and helps you ensure that your application
is complete.

Each page of the application should be numbered consecutively with
numbers centered at the bottom of the page. The State's name must be
entered on every form. The application should be clipped or stapled
securely, but not bound to hinder reproduction.

If you are using WEB-BGAS, the State need only print out the six
Certifications/Assurances (Form 3), Assurances Non-Construction
Programs, and Certifications, sign and mail them early enough to arrive
at SAMHSA by October 1, 2004.

Copies of the uniform application and forms are available in MS Word
from CSAT via the SAMHSA/CSAT home page. To download the application, go
to:

<http://www.tie.samhsa.gov/sapt2005.htm>

Directions to download and decompress the files are available on the
page.

**Footnotes**

Your State may wish to add footnotes to data forms to qualify or
otherwise explain data entries. You may do so on any form in the
application. If you are using the WEB-BGAS you should click on the
footnote button and enter the information you desire. If you are using
the MS Word version you may use the footnote feature found under the
"Insert" pull down menu on most MS Word versions.

**What to do if your State cannot complete all items in Sections I-III**

If your State does not have reliable data to complete an item on the
application, or if you cannot get sufficient information to respond
fully by the due date, do [not]{.underline} leave the item blank.
Instead, use one of these options:

Provide a clear explanation of your problem in obtaining the data.

 Describe the alternative method of data collection you use.

Explain how you carry out the activity.

Whenever you have a problem completing an item, describe what kind of
financial or technical assistance you would need to improve your
response in future years.

**Getting assistance in completing the application**

If you have questions about programmatic issues, you may call CSAT's
Division of State and Community Assistance, Performance Partnership
Grant Branch at (240) 276-2890 or CSAP's Division of State and Community
Systems Development, Systems Application Branch at (240) 276-2570 and
ask for your respective State project officer or contact the State
project officer directly by telephone or Internet e-mail using the
directory provided ([See]{.underline} Appendix A). If you have questions
about fiscal or grants management issues, you may call the Grants
Management Officer, Office of Program Services, Division of Grants
Management, at (240) 276-1404.

**SECTION I**

This section of the application has three items:

1.  Face Page (Form 1)

2.  Table of Contents (Form 2)

3.  Funding Agreements/Certifications (Form 3)

> Assurances-Non-Construction Programs
>
> Certifications

**1. Face Page**

This form is pre-numbered as page 1 in WEB-BGAS. It requires the entry
of identifying information and is self-explanatory. However, please take
special note of the following:

-   Item I, State Agency to be the Grantee for the Block Grant, requires
    both the name of the responsible agency designated by the Governor
    as the official grantee **and** the name of the organizational unit
    within that agency that administers the block grant.

-   Item II, Contact Person for the Grantee of the Block Grant, requires
    identifying the person with overall responsibility for the block
    grant.

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-   Item III, State Expenditure Period, is the **most recent** 12-month
    State expenditure period for which expenditure information is
    complete. This is probably the most recent State fiscal year that is
    closed out. When you submit next year for the FY 2006 award, your
    State Expenditure period will be the **next** consecutive 12-month
    period.

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-   Item IV, Date Submitted, is the calendar date on which the uniform
    block grant application is submitted to SAMHSA.

-   Item V, Contact Person Responsible For Application Submission, is
    the name of the individual to whom SAMHSA should address comments
    and/or questions concerning the content of the uniform block grant
    application.

**2. Table of Contents**

The Table of Contents shows exactly how to assemble and order your
application. If you are using WEB-BGAS, Form 2 is a checklist that will
help you see all the required Forms and checklists and which have at
least some data entered on them. Once all items listed on Form 2 are
complete, a State need only read, print, sign, and mail Form 3,
Assurances-Non-Construction Programs, and Certifications to complete
their application.

If you are using a method other than WEB-BGAS, complete the uniform
application (checklists, forms, and narrative) and enter the page
numbers as appropriate. Remember that every page in the application,
including forms, must be consecutively numbered. The Table of Contents
is pre-numbered and starts on page 2. You can still use the Table of
Contents as a checklist to ensure that your application is complete.

**3. Funding Agreements/Certifications**

The following three standard forms must be signed by the Chief Executive
Officer or an authorized designee and submitted with this application.
Documentation authorizing a designee must be attached to the
application.

**I. Chief Executive Officer's Funding Agreements/Certifications (Form
3)**

**II. Certifications**

1.  **Certification Regarding Debarment and Suspension**

2.  **Certification Regarding Drug-Free Workplace Requirements**

> This certification is included in the application package. It has to
> be submitted only if a Statewide or agency-wide annual assurance has
> not been submitted to DHHS.

3.  **Certifications Regarding Lobbying and Disclosure**

> This certification, included in the application package, must be
> signed and submitted before the award of any Federal grant or
> cooperative agreement exceeding \$100,000.

4.  **Certification Regarding Program Fraud Civil Remedies Act (PFCRA)**

5.  **Certification Regarding Environmental Tobacco Smoke**

**III. Assurances-Non-Construction Programs**

> (See Appendix A)

**SECTION II: ANNUAL REPORT**

**ACTUAL USE OF FY 2002**

**SAPT BLOCK GRANT FUNDS**

This section documents how the State used the FY 2002 award to meet the
goals, objectives, and activities described in the application for those
funds. Therefore, it is helpful to review the FY 2002 application (and
any modifications or revisions that may have been made) before you
complete this section. This information is required by section 1942 of
the Public Health Service (PHS) Act ([See]{.underline} 42 U.S.C.
300x-52). It addresses the report requirements of the SAPT Block Grant.

Section II refers to the statutory and regulatory requirements of the
PHS Act, as amended ([See]{.underline} 42 U.S.C. 300x-21 et. seq. and 45
C.F.R. Part 96).

By the time you complete this report, the State will have **spent** the
FY 2002 block grant award and **obligated** the FY 2003 award.
Therefore, all financial data requested should be available to you.

This section has five items. It requires completing four checklists,
addressing the 17 Federal Goals for the FY 2002, 2004, and 2005
narratives, five forms, and four tables. Here is an overview of the
requirements.

+---+----------------------------------------+------------------------+
|   | Item                                   | What you need to       |
|   |                                        | submit                 |
+---+----------------------------------------+------------------------+
| 1 | How allotments were used               | Checklist              |
| \ |                                        |                        |
| . |                                        |                        |
+---+----------------------------------------+------------------------+
| 2 | How substance abuse funds were used:   | Form 4 and four        |
| \ | FY 2002 Annual Report; FY 2004         | checklists             |
| . | Progress Report;                       |                        |
|   |                                        |                        |
|   | FY 2005 Intended Use; and Attachments  |                        |
|   | (A-K).                                 |                        |
+---+----------------------------------------+------------------------+
| 3 | Entity Inventory; Prevention Strategy  | Form 6 and Form 6A     |
| \ | Report                                 |                        |
| . |                                        |                        |
+---+----------------------------------------+------------------------+
| 4 | Treatment Utilization Matrix; Number   | Form 7A and Form 7B    |
| \ | of Persons for Alcohol and Other Drug  |                        |
| . | Use in State-Funded Services By Age,   |                        |
|   | Sex, and Race/Ethnicity (Unduplicated  |                        |
|   | Count)                                 |                        |
+---+----------------------------------------+------------------------+
| 5 | Maintenance of Effort (MOE) Tables:    | Tables I -- IV         |
| \ | Total Single State Agency Expenditures |                        |
| . | for Substance Abuse; Statewide         |                        |
|   | Non-Federal Expenditures for           |                        |
|   | Tuberculosis Services for Substance    |                        |
|   | Abusers in Treatment; Statewide        |                        |
|   | Non-Federal Expenditures for HIV Early |                        |
|   | Intervention Services to Substance     |                        |
|   | Abusers in Treatment; and Expenditures |                        |
|   | for Services to Pregnant Women and     |                        |
|   | Women With Dependent Children          |                        |
|   | (Maintenance)                          |                        |
+---+----------------------------------------+------------------------+

**1. How allotments were used.**

Enter the amount of the FY 2002 SAPT Block Grant that appears on line 8
of the Notice of Block Grant Award \$ .

**2. How substance abuse funds were used and intended (narrative).**

NARRATIVES (FEDERAL GOALS FY 2002, FY 2004, AND FY 2005) AND ATTACHMENTS

Narratives for the Federal Goals must be addressed for FY 2002, 2004,
and 2005 under each Federal Goal respectively.

In addressing the 16 Federal Goals for **FY 2002** describe, in a brief
narrative, how the SAPT Block Grant funds were used to meet the
**treatment and primary prevention goals, objectives, and activities**
spelled out in the State's FY 2002 application. Be sure to specify the
primary prevention activities performed for each of the six strategies.
Include a description of the State's policies, procedures, and laws
regarding substance abuse treatment, and information on what programs
and activities were supported, what services were provided, and what
progress was made ([See]{.underline} 42 U.S.C. 300x-52 and 45 C.F.R.
96.122(f)(1)(ii)).

In addressing the 16 Federal Goals for **FY 2004**, provide a
description of the State's progress in meeting the **treatment and
primary prevention goals, objectives, and activities** included in the
FY 2004 application and a brief description of the recipients of block
grant funds. For primary prevention, the description should also address
the State's progress in performing the activities for the six strategies
articulated in the FY 2004 application, as well ([See]{.underline} 42
U.S.C. 300x-52 and 45 C.F.R. 96.122(f)(5)(i)).

In addressing the 17 Federal Goals for **FY 2005**, describe the State's
intended use of block grant funds and the specific **treatment and
primary prevention goals, objectives, and activities** the State will
carry out to achieve these objectives. At a minimum, the narrative must
address the following:

In an effort to provide more concrete guidance on the essential points
that must be covered in the narratives, the following questions must be
addressed when responding to each.

\(1\) Who will be served -- describe the target population and provide
an estimate of the number of persons to be served in the target
population;

\(2\) What activities/services will be provided, expanded, or enhanced
-- this may include activities/services by treatment modality or
prevention strategy;

\(3\) When will the activities/services be implemented (date) -- for
ongoing activities/services, include information on the progress toward
meeting the goals including dates on which integral activities/services
began or will begin;

\(4\) Where in the State (geographic area) will the activities/services
be undertaken -- this may include counties, districts, regions, or
cities;

(5) How will the activities/services be operationalized -- this may be
    through direct

procurement, subcontractors or grantees, or intra governmental
agreements.

As an example, in response to the narrative on planned
activities/services regarding the expansion of existing or creation of
new programs for pregnant women and women with dependent children, a
State might provide the following information:

> "It is planned in FY 2005 to provide residential treatment services to
> 200 women with dependent children. In addition to providing
> residential treatment for women, facilities will be provided to allow
> the housing of minor children during the course of the treatment
> episode. This program is scheduled to be implemented in May 2005 in
> the four counties of the State that have the highest prevalence of
> substance abuse among women. We intend to fund this activity through a
> competitive contract with licensed, accredited providers in the four
> counties."

To complete the 17 Federal goals**,** objectives, and activities for the
intended use plan, please address the Federal block grant requirements
in a separate section **first** and then you may add an additional
section describing other State requirements. [List the specific
objectives under each requirement and goal in priority
order.]{.underline} Describe what activities the State plans to
undertake to achieve these objectives. Include key elements in the
State's strategy to improve existing programs, create new ones, and
remove barriers to improvement and expansion. Keep your discussion of
**each** goal or requirement, its objectives, and activities to **no
more than one page per reporting year.**

The application requires 10 attachments (A-J). These are in narrative or
checklist form and follow the related Federal goals below.

**GOAL \# 1.** The State shall expend block grant funds to maintain a
continuum of substance abuse treatment services that meet these needs
for the services identified by the State. Describe the continuum of
block grant-funded treatment services available in the State
([See]{.underline} 42 U.S.C. 300x-21(b) and 45 C.F.R. 96.122(f)(g)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**GOAL \# 2.** An agreement to spend not less than 20 percent on primary
prevention programs for individuals who do not require treatment for
substance abuse, specifying the activities proposed for each of the six
strategies ([See]{.underline} 42 U.S.C. 300x-22(b)(1) and 45 C.F.R.
96.124(b)(1)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**Attachment A: Prevention**

Answer the following questions about the **current year** status of
policies, procedures, and legislation in your State. Most of the
questions are related to [Healthy]{.underline} [People]{.underline}
[2010]{.underline} objectives. References to these objectives are
provided for each applicable question. To respond, check the appropriate
box or enter numbers on the blanks provided. After you have completed
your answers, copy the attachment and submit it with your application.

1\. Does your State conduct sobriety checkpoints on major and minor
thoroughfares on a periodic basis? (HP 26-25)

 Yes  No  Unknown

2\. Does your state conduct or fund prevention/education activities
aimed at preschool children? (HP 26-9)

 Yes  No  Unknown

3\. Does your State alcohol and drug agency conduct or fund
prevention/education activities in every school district aimed at youth
grades K-12? (HP 26-9)

+----------------------+------------------------+----------------------+
| SAPT BLOCK GRANT     | OTHER STATE FUNDS      | DRUG FREE SCHOOLS    |
+----------------------+------------------------+----------------------+
|  Yes                |  Yes                  |  Yes                |
|                      |                        |                      |
|  No                 |  No                   |  No                 |
|                      |                        |                      |
|  Unknown            |  Unknown              |  Unknown            |
+----------------------+------------------------+----------------------+

4\. Does your State have laws making it illegal to consume alcoholic
beverages on the campuses of State colleges and universities? (HP 26-11)

 Yes  No  Unknown

5\. Does your State conduct prevention/education activities aimed at
college students that include: (HP 26-11c)

Education bureau?  Yes  No  Unknown

Dissemination of materials?  Yes  No  Unknown

Media campaigns?  Yes  No  Unknown

Product pricing strategies?  Yes  No  Unknown

Policy to limit access?  Yes  No  Unknown

6\. Does your State now have laws that suspend or revoke administrative
drivers' licenses for those determined to have been driving under the
influence of intoxicants? (HP 26-24)

 Yes  No  Unknown

7\. Has the State enacted and enforced new policies in the last year to
reduce access to alcoholic beverages by minors such as (HP 26-11c, 12,
23):

> Restrictions at recreational and entertainment events at which youth
> made up a majority of participants/consumers?

 Yes  No  Unknown

New product pricing?

 Yes  No  Unknown

New taxes on alcoholic beverages?

 Yes  No  Unknown

> New laws or enforcement of penalties and license revocation for sale
> of alcoholic beverages to minors?

 Yes  No  Unknown

Parental responsibility laws for a child's possession and use of
alcoholic beverages?

 Yes  No  Unknown

8\. Does your State provide training and assistance activities for
parents regarding alcohol, tobacco, and other drug use by minors?

 Yes  No  Unknown

9\. What is the average age of first use for the following? (HP 26-9 and
27-4, if available)

[Age 0-5]{.underline} [Age 6-11]{.underline} [Age 12-14]{.underline}
[Age 15-18]{.underline}

Cigarettes

Alcohol

Marijuana

10\. What is your State's present legal alcohol concentration tolerance
level for: (HP 26-25)

Motor vehicle drivers age 21 and older?

Motor vehicle drivers under age 21?

11\. How many communities in your State have comprehensive,
community-wide coalitions for alcohol and other drug abuse prevention
(HP 26-3)? \_\_\_\_\_\_\_\_

12\. Has your State enacted statutes to restrict promotion of alcoholic
beverages and tobacco that are focused principally on young audiences,
(HP 26-11 and 26-16)?

 Yes  No  Unknown

**GOAL \# 3.** An agreement to expend not less than an amount equal to
the amount expended by the State for FY 1994 to establish new programs
or expand the capacity of existing programs to make available treatment
services designed for pregnant women and women with dependent children;
and, directly or through arrangements with other public or nonprofit
entities, to make available prenatal care to women receiving such
treatment services, and, while the women are receiving services, child
care ([See]{.underline} 42 U.S.C. 300x-22(b)(1)(C) and 45 C.F.R.
96.124(c)(e)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**Attachment B: Programs for Pregnant Women and Women with Dependent
Children**

([See]{.underline} 42 U.S.C. 300x-22(b); 45 C.F.R. 96.124(c)(3); and 45
C.F.R. 96.122(f)(1)(viii))

**For the fiscal year three years prior** **(FY 2002) to the fiscal year
for which the State is applying for funds:**

Refer back to your Substance Abuse Entity Inventory (Form 6). Identify
those projects serving pregnant women and women with dependent children
and the types of services provided in FY 2002. In a narrative of **up to
two pages,** describe these funded projects.

The PHS Act required the State to expend at least 5 percent of the FY
1993 and FY 1994 block grants to increase (relative to FY 1992 and FY
1993, respectively) the availability of treatment services designed for
pregnant women and women with dependent children. In the case of a grant
for any subsequent fiscal year, the State will expend for such services
for such women not less than an amount equal to the amount expended by
the State for fiscal year 1994.

**In up to four pages, answer the following questions:**

1\. Identify the name, location (include sub-State planning area),
Inventory of Substance Abuse Treatment Services (I-SATS) ID number
(formerly the National Facility Register (NFR) number), type of care
(refer to definitions in Section II.5), capacity, and amount of funds
made available to each program designed to meet the needs of pregnant
women and women with dependent children.

2\. What did the State do to ensure compliance with 42 U.S.C.
300x-22(b)(1)(C) in spending FY 2002 block grant funds?

3\. What special methods did the State use to **monitor** the adequacy
of efforts to meet the special needs of pregnant women and women with
dependent children?

4\. What sources of data did the State use in estimating treatment
capacity and utilization by pregnant women and women with dependent
children?

5\. What did the State do with FY 2002 block grant funds to establish
new programs or expand the capacity of existing programs for pregnant
women and women with dependent children?

**GOAL \# 4.** An agreement to provide treatment to intravenous drug
abusers that fulfills the 90 percent capacity reporting, 14-120 day
performance requirement, interim services, outreach activities and
monitoring requirements ([See]{.underline} 42 U.S.C. 300x-23 and 45
C.F.R. 96.126).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**Attachment C: Programs for Intravenous Drug Users (IVDUs)**

([See]{.underline} 42 U.S.C. 300x-23; 45 C.F.R. 96.126; and 45 C.F.R.
96.122(f)(1)(ix)

**For the fiscal year three years prior (FY 2002) to the fiscal year for
which the State is applying for funds:**

1\. How did the State define IVDUs in need of treatment services?

2\. What did the State do to ensure compliance with 42 U.S.C. 300x-23 of
the PHS Act as such sections existed after October 1, 1992, in spending
FY 2002 SAPT Block Grant funds ([See]{.underline} 45 C.F.R. 96.126(a))?

3\. What did the State do to ensure compliance with 42 U.S.C.
300x-31(a)(1)(F) of the PHS Act prohibiting the distribution of sterile
needles for injection of any illegal drug ([See]{.underline} 45 C.F.R.
96.135(a)(6))?

4\. 42 U.S.C. 300x-23(a)(1) requires that any program receiving amounts
from the grant to provide treatment for intravenous drug abuse notify
the State when the program has reached 90 percent of its capacity.
Describe how the State ensured that this was done. Please provide a list
of all such programs that notified the State during FY 2002 and include
the program's I-SATS ID number ([See]{.underline} 45 C.F.R. 96.126(a)).

5\. 42 U.S.C. 300x-23(a)(2)(A)(B) requires that an individual who
requests and is in need of treatment for intravenous drug abuse is
admitted to a program of such treatment within 14-120 days. Describe how
the State ensured that such programs were in compliance with the 14-120
day performance requirement ([See]{.underline} 45 C.F.R. 96.126(b)).

6\. 42 U.S.C. 300x-23(b) requires any program receiving amounts from the
grant to provide treatment for intravenous drug abuse to carry out
activities to encourage individuals in need of such treatment to undergo
treatment. Describe how the State ensured that outreach activities
directed toward IVDUs was accomplished ([See]{.underline} 45 C.F.R.
96.126(e)).

**Attachment D: Program Compliance Monitoring**

(See 45 C.F.R. 96.122(f)(3)(vii))

The Interim Final Rule (45 C.F.R. Part 96) requires effective strategies
for monitoring programs' compliance with the following sections of the
PHS Act: 42 U.S.C. 300x-23(a); 42 U.S.C. 300x-24(a); and 42 U.S.C.
300x-27(b).

**For the fiscal year two years prior (FY 2003) to the fiscal year for
which the State is applying for funds:**

In **up to three pages** provide the following:

-   A description of the strategies developed by the State for
    monitoring compliance with each of the sections identified below:

1\. **Notification of Reaching Capacity** 42 U.S.C. 300x-23(a)

> ([See]{.underline} 45 C.F.R. 96.126(f) and 45 C.F.R.
> 96.122(f)(3)(vii));

2\. **Tuberculosis Services** 42 U.S.C. 300x-24(a)

> ([See]{.underline} 45 C.F.R. 96.127(b) and 45 C.F.R.
> 96.122(f)(3)(viii)); and

3\. **Treatment Services for Pregnant Women** 42 U.S.C. 300x-27(b)

([See]{.underline} 45 C.F.R. 96.131(f) and 45 C.F.R. 96.122(f)(3)(vii)).

-   A description of the problems identified and corrective actions
    taken.

**GOAL \# 5.** An agreement, directly or through arrangements with other
public or nonprofit private entities, to routinely make available
tuberculosis services to each individual receiving treatment for
substance abuse and to monitor such service delivery ([See]{.underline}
42 U.S.C. 300x-24(a) and 45 C.F.R. 96.127).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**GOAL \# 6.** An agreement, by designated States, to provide treatment
for persons with substance abuse problems with an emphasis on making
available within existing programs early intervention services for HIV
in areas of the State that have the greatest need for such services and
to monitor such service delivery ([See]{.underline} 42 U.S.C. 300x-24(b)
and 45 C.F.R. 96.128).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**Attachment E: Tuberculosis (TB) and Early Intervention Services for
HIV**

(See 45 C.F.R. 96.122(f)(1)(x))

**For the fiscal year three years prior (FY 2002) to the fiscal year for
which the State is applying for funds:**

Provide a description of the State's procedures and activities and the
total funds expended (or obligated if expenditure data is not available)
for tuberculosis services. If a "designated State," provide funds
expended (or obligated), for early intervention services for HIV.

Examples of **procedures** include, but are not limited to:

-   development of procedures (and any subsequent amendments), for
    tuberculosis services and, if a designated State, early intervention
    services for HIV, e.g., Qualified Services Organization Agreements
    (QSOA) and Memoranda of Understanding (MOU);

-   the role of the single State authority (SSA) for substance abuse
    prevention and treatment; and

-   the role of the single State authority for public health and
    communicable diseases.

Examples of **activities** include, but are not limited to:

-   the type and amount of training made available to providers to
    ensure that tuberculosis services are routinely made available to
    each individual receiving treatment for substance abuse;

-   the number and geographic locations (include sub-State planning
    area) of projects delivering early intervention services for HIV;

-   the linkages between IVDU outreach ([See]{.underline} 42 U.S.C.
    300x-23(b) and 45 C.F.R. 96.126(e)) and the projects delivering
    early intervention services for HIV; and

-   technical assistance.

**GOAL \# 7.** An agreement to continue to provide for and encourage the
development of group homes for recovering substance abusers through the
operation of a revolving loan fund ([See]{.underline} 42 U.S.C. 300x-25
and 45 C.F.R. 96.129). [Effective FY 2001, the States may choose to
maintain such a fund]{.underline}. If a State chooses to participate,
reporting is required.

**FY 2002 (Compliance):** (participation OPTIONAL)

**FY 2004 (Progress):** (participation [OPTIONAL]{.underline})

**FY 2005 (Intended Use):** (participation [OPTIONAL]{.underline})

**Attachment F: Group Home Entities and Programs**

([See]{.underline} 42 U.S.C. 300x-25; 45 C.F.R. 96.129; and 45 C.F.R.
96,122(f)(1)(vii))

Provide a list of all entities that have received loans from the
revolving fund during FY 2002 to establish group homes for recovering
substance abusers. In a narrative of **up to two pages,** describe the
following:

-   the number and amount of loans made available during the applicable
    fiscal years;

-   the amount available in the fund throughout the fiscal year;

-   the source of funds used to establish and maintain the revolving
    fund;

-   the loan requirements, application procedures, the number of loans
    made, the number of repayments, and any repayment problems
    encountered;

-   the private, nonprofit entity selected to manage the fund;

-   any written agreement that may exist between the State and the
    managing entity;

-   how the State monitors fund and loan operations; and

-   any changes from previous years' operations.

**GOAL \# 8.** An agreement to continue to have in effect a State law
that makes it unlawful for any manufacturer, retailer, or distributor of
tobacco products to sell or distribute any such product to any
individual under the age of 18; and, to enforce such laws in a manner
that can reasonably be expected to reduce the extent to which tobacco
products are available to individuals under age 18 ([See]{.underline} 42
U.S.C. 300x-26 and 45 C.F.R. 96.130).

-   Is the State's Synar report included with the FY 2004 uniform
    application?

Yes No

-   If No, please indicate when the State plans to submit the report:

> mm/dd/2004

**GOAL \# 9.** An agreement to ensure that each pregnant woman be given
preference in admission to treatment facilities; and, when the facility
has insufficient capacity, to ensure that the pregnant woman be referred
to the State, which will refer the woman to a facility that does have
capacity to admit the woman, or if no such facility has the capacity to
admit the woman, will make available interim services within 48 hours,
including a referral for prenatal care ([See]{.underline} 42 U.S.C.
300x-27 and 45 C.F.R. 96.131).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

> **FY 2005 (Intended Use):**

**Attachment G: Capacity Management and Waiting List Systems**

([See]{.underline} 45 C.F.R. 96.122(f)(3)(vi))

**For the fiscal year two years prior (FY 2003) to the fiscal year for
which the State is applying for funds:**

In **up to five pages,** provide a description of the State's procedures
and activities undertaken, and the total amount of funds expended (or
obligated if expenditure data is not available), to comply with the
requirement to develop capacity management and waiting list systems for
intravenous drug users and pregnant women ([See]{.underline} 45 C.F.R.
96.126(c) and 45 C.F.R. 96.131(c), respectively). This report should
include information regarding the utilization of these systems. Examples
of **procedures** may include, but not be limited to:

-   development of procedures (and any subsequent amendments) to
    reasonably implement a capacity management and waiting list system;

-   the role of the Single State Authority (SSA) for substance abuse
    prevention and treatment;

-   the role of intermediaries (county or regional entity), if
    applicable, and substance abuse treatment providers; and

-   the use of technology, e.g., toll-free telephone numbers, automated
    reporting systems, etc.

Examples of **activities** may include, but not be limited to:

-   how interim services are made available to individuals awaiting
    admission to treatment;

-   the mechanism(s) utilized by programs for maintaining contact with
    individuals awaiting admission to treatment; and

-   technical assistance

**GOAL \# 10.** An agreement to improve the process in the State for
referring individuals to the treatment modality that is most appropriate
for the individual ([See]{.underline} 42 U.S.C. 300x-28(a) and 45 C.F.R.
96.132(a)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

> **FY 2005 (Intended Use):**

**GOAL \# 11.** An agreement to provide continuing education for the
employees of facilities which provide [prevention activities or
treatment services (or both as the case may be)]{.underline}
([See]{.underline} 42 U.S.C. 300x-28(b) and 45 C.F.R. 96.132(b)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**GOAL \# 12.** An agreement to coordinate [prevention activities and
treatment services]{.underline} with the provision of other appropriate
services ([See]{.underline} 42 U.S.C. 300x-28(c) and 45 C.F.R.
96.132(c)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

> **FY 2004 (Intended Use):**

**GOAL \# 13.** An agreement to submit an assessment of the need for
both treatment and prevention in the State for authorized activities,
both by locality and by the State in general ([See]{.underline} 42
U.S.C. 300x-29 and 45 C.F.R. 96.133).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

> **FY 2005 (Intended Use):**

**GOAL \# 14.** An agreement to ensure that no program funded through
the block grant will use funds to provide individuals with hypodermic
needles or syringes so that such individuals may use illegal drugs
([See]{.underline} 42 U.S.C. 300x-31(a)(1)(F) and 45 C.F.R.
96.135(a)(6)).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

**GOAL \# 15.** An agreement to assess and improve, through independent
peer review, the quality and appropriateness of treatment services
delivered by providers that receive funds from the block grant
([See]{.underline} 42 U.S.C. 300x-53(a) and 45 C.F.R. 96.136).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

> **FY 2005 (Intended Use):**

**Attachment H: Independent Peer Review** ([See]{.underline} 45 C.F.R.
96.122(f)(3)(v))

**For the fiscal year two years prior (FY 2003) to the fiscal year for
which the State is applying for funds:**

In **up to three pages** provide a description of the State's procedures
and activities undertaken to comply with the requirement to conduct
independent peer review during FY 2003 ([See]{.underline} 42 U.S.C.
300x-53(a)(1) and 45 C.F.R. 96.136).

Examples of **procedures** may include, but not be limited to:

-   the role of the single State authority (SSA) for substance abuse
    prevention activities and treatment services in the development of
    operational procedures implementing independent peer review;

-   the role of the State Medical Director for Substance Abuse Services
    in the development of such procedures;

-   the role of the independent peer reviewers; and

-   the role of the entity(ies) reviewed.

Examples of **activities** may include, but not be limited to:

-   the number of entities reviewed during the applicable fiscal year;

-   technical assistance made available to the entity(ies) reviewed; and

-   technical assistance made available to the reviewers, if applicable.

**GOAL \# 16.** An agreement to ensure that the State has in effect a
system to protect patient records from inappropriate disclosure
([See]{.underline} 42 U.S.C. 300x-53(b), 45 C.F.R. 96.132(e), and 42
C.F.R. part 2).

**FY 2002 (Compliance):**

**FY 2004 (Progress):**

> **FY 2005(Intended Use):**

**GOAL #17.** An agreement to ensure that the State has in effect a
system to comply with 42 U.S.C. 300x-65 and 42 C.F.R. part 54
([See]{.underline} 42 C.F.R. 54.8(c)(4) and 54.8(b), Charitable Choice
Provisions and Regulations.

**FY 2002 (Compliance):** Not Applicable

**FY 2004 (Progress):**

**FY 2005 (Intended Use):**

Under Charitable Choice, States, local governments, and religious
organizations, each as SAMHSA grant recipients, must: (1) ensure that
religious organizations that are providers provide notice of their right
to alternative services to all potential and actual program
beneficiaries (services recipients); (2) ensure that religious
organizations that are providers refer program beneficiaries to
alternative services; and (3) fund and/or provide alternative services.
The term "alternative services" means services determined by the State
to be accessible and comparable and provided within a reasonable period
of time from another substance abuse provider ("alternative provider")
to which the program beneficiary ("services recipient") has no religious
objection.

The purpose of Attachment I is to document how your State is complying
with these provisions.

Attachment I -- Charitable Choice

For the fiscal year prior (FY 2004) to the fiscal year for which the
State is applying for funds provide a description of the State's
procedures and activities undertaken to comply with the provisions.

**Notice to Program Beneficiaries** -- Check all that apply:

>  Use model notice provided in final regulations.

-   Use notice developed by State (attached copy).

-   State has disseminated notice to religious organizations that are
    providers.

-   State requires these religious organizations to give notice to all
    potential beneficiaries.

**Referrals to Alternative Services** -- Check all that apply:

-   State has developed specific referral system for this requirement.

-   State has incorporated this requirement into existing referral
    system(s).

>  SAMHSA's Treatment Facility Locator is used to help identify
> providers.
>
>  Other networks and information systems are used to help identify
> providers.
>
>  State maintains record of referrals made by religious organizations
> that are providers.
>
>  Enter total number of referrals necessitated by religious objection
> to other substance abuse providers ("alternative providers"), as
> defined above, made in previous fiscal year. Provide total
> [only]{.underline}; no information on specific referrals required.

**NOTE:** States have the option to postpone specific reporting on
referrals until the submission of the FY 2006 uniform application
(October 1, 2005).

**Brief description (one paragraph)** of any training for local
governments and faith-based and community organizations on these
requirements.

**Attachment J: Waivers**

If your State plans to apply for any of the following waivers, check the
appropriate box and submit the request for a waiver at the earliest
possible date.

 To expend not less than an amount equal to the amount expended by the
State for FY 1994 to establish new programs or expand the capacity of
existing programs to make available treatment services designed for
pregnant women and women with dependent children ([See]{.underline} 42
U.S.C. 300x-22(b)(2) and 45 C.F.R. 96.124(d)).

 Rural area early intervention services HIV requirements

([See]{.underline} 42 U.S.C. 300x-24(b)(5)(B) and 45 C.F.R. 96.128(d))

 Improvement of process for appropriate referrals for treatment,
continuing education, or coordination of various activities and services

> ([See]{.underline} 42 U.S.C. 300x-28(d) and 45 C.F.R. 96.132(d)

 Statewide maintenance of effort (MOE) expenditure levels

([See]{.underline} 42 U.S.C. 300x-30(c) and 45 C.F.R. 96.134(b))

 Construction/rehabilitation

([See]{.underline} 42 U.S.C. 300x-31(c) and 45 C.F.R. 96.135(d))

If your State proposes to request a waiver at this time for one or more
of the above provisions, include the waiver request as Attachment J to
the application. The Interim Final Rule, 45 C.F.R. 96.124(d), 96.128(d),
96.132(d), 96.134(b), and 96.135(d), contains information regarding the
criteria for each waiver, respectively.

**[Description of Calculations]{.underline}**

In a brief narrative, provide a description of the amounts and methods
used to calculate the following: (a) the base for services to pregnant
women and women with dependent children as required by 42 U.S.C.
300x-22(b)(1); and, for 1994 and subsequent fiscal years report the
Federal and State expenditures for such services; (b) the base and
Maintenance of Effort (MOE) for tuberculosis services as required by 42
U.S.C. 300x-24(d); and, (c) for designated States, the base and MOE for
HIV early intervention services as required by 42 U.S.C. 300x-24(d)
([See]{.underline} 45 C.F.R. 96.122(f)(5)(ii)(A)(B)(C)).

**Preparing to complete the Substance Abuse State Agency Spending Report
(Form 4)**

This form requires you to enter amounts of funds, by source, for each
kind of activity. You will enter **only** funds flowing through the
principal agency of the State that administered the SAPT Block Grant.
Amounts must be entered in whole dollar amounts. Before you begin
completing the form, do the following:

-   Enter the State's name in the box at the upper **left**.

-   Enter in the box at the upper **right** the dates of the State
    expenditure period you identified on the Face Page (Form 1).

-   Read the instructions carefully.

-   Study the definitions of the row and column headings.

**How to complete Form 4**

First review the definitions of the activities listed at the left. Then
make sure you understand which fund sources are entered in column A and
which ones are entered in columns B through F.

**Rows 1 through 5 -- Activities**

Rows 1 through 5 describe typical activities funded by the agency
administering the SAPT Block Grant.

 Note**:** Do [not]{.underline} include expenditures for primary
prevention in Row 1.

**Row 1: Substance Abuse Treatment and Rehabilitation** -- This includes
direct services to patients, such as outreach, detoxification, methadone
detoxification and maintenance, outpatient counseling, residential
rehabilitation including therapeutic community stays, hospital-based
care, vocational counseling, case management, central intake, and
program administration.

**Row 2: Primary Prevention** -- This row collects information on
primary prevention activities funded under the FY 2002 SAPT Block Grant.
Primary prevention includes activities directed at individuals who do
not require treatment for substance abuse. Such activities may include
education, counseling, and other activities designed to reduce the risk
of substance abuse by individuals. Note that under the SAPT Block Grant
statute, **early intervention activities are not included as part of
primary prevention**. Early intervention activities funded in FY 1993
and subsequent fiscal years should be included as part of row 1.

**Row 3: Tuberculosis Services** -- This row collects information on
tuberculosis services made available to individuals receiving treatment
for substance abuse. Tuberculosis services include counseling, testing,
and treatment for the disease. Funds made available from the grant to
provide such services, either directly or through arrangements with
other public or nonprofit private entities, should be recorded on row 3,
column A.

**Row 4: HIV Early Intervention Services** -- This row collects
information on 1 or more projects established to make available early
intervention services for HIV disease at the sites in which individuals
are receiving treatment for substance abuse. Funds made available from
the grant

[\>]{.underline} 2 percent [\<]{.underline} 5 percent, to establish such
projects should be recorded on row 4, column A. This row is applicable
to those "designated States" whose rate of cases of acquired immune
deficiency syndrome is equal to or greater than the case rate specified
in the statute. The case rate data, as indicated by the number of such
cases reported to and confirmed by the Director of the Centers for
Disease Control and Prevention for the most recent calendar for which
such data are available[^2], refers to such data that is available on or
before October 1 of the fiscal year for which the State is applying for
a grant.

**Row 5: Administration** -- This includes grants and contracts
management, policy and auditing, personnel management, legislative
liaison, and other overhead costs in large departments and agencies. For
FY 2002, a maximum of 5 percent of the SAPT Block Grant may have been
spent on administration at the State level.

Do [not]{.underline} account for administration at the program (or
service provider) level on this row. Program level administration
expenditures should be accounted for in Rows 1 - 4 above, as
appropriate.

**Row 6: Column Total --** Use this row to enter the total of Rows 1
through 5. The column A total amount should equal the amount of the FY
2002 SAPT Block Grant that appears on line 8 of the Notice of Block
Grant Award (NGA).

**Column A -- Expenditures of SAPT Block Grant**

Use these columns to record your State's use of FY 2002 SAPT Block Grant
awards. In column A, enter FY 2002 block grant funds that were spent on
each activity. Remember to enter amounts in whole dollar amounts.

**Columns B through F -- Expenditures of other funds**

Use these columns to report on funds from other sources spent by the
designated substance abuse agency **during the 12-month expenditure
period you entered in the box**. [Thus, the time period on which you
report here is different from the one covered by column A]{.underline}.
Here are the definitions for each column:

**Column B: Medicaid** -- Enter the total of all Federal, State and
local match Medicaid funds in this column.

**Column C: Other Federal funds** -- This includes all other Federal
funds for substance abuse that flow through the principal agency.
Examples are HHS or other Federal categorical grant funds, Medicare,
other public welfare funds such as Food Stamps (Title VIII), other
public third party funds such as CHAMPUS, the Social Services Block
Grant (Title XX), and the Maternal and Child Health Block Grant (Title
V). Do [not]{.underline} include Federal funds that go through other
State offices/agencies or directly to providers.

**Column D: State funds --** This includes all State general funds or
special appropriations administered by the principal agency, such as
fines, fees, and earmarked taxes. This column provides an estimate of
annual State funding.

**Column E: Local funds** -- This includes appropriations from local
government entities such as cities, other municipalities, special tax
districts, and counties. Remember that local Medicaid match funds were
reported in column B. Do **[not]{.underline}** report them again here.

**Column F: Other funds** -- This includes funds from all other sources
such as patient fees, nonprofit private entities like the United Way and
the Robert Wood Johnson Foundation, and private third party payers such
as Blue Cross/Blue Shield, health maintenance organizations, and other
commercial insurers. If your agency receives no local or other funds,
enter zeroes in columns E and F.

**[Detailing expenditures on primary prevention (Row 2)]{.underline}**

There are six primary prevention strategies typically funded by
principal agencies administering the SAPT Block Grant. Here are the
definitions of those strategies. PLEASE NOTE: CATEGORY FOR REPORTING
COSTS ASSOCIATED WITH IMPLEMENTING SECTION 1926--TOBACCO.

**Information Dissemination** -- This strategy provides knowledge and
increases awareness of the nature and extent of alcohol and other drug
use, abuse, and addiction, as well as their effects on individuals,
families, and communities. It also provides knowledge and increases
awareness of available prevention and treatment programs and services.
It is characterized by one-way communication from the source to the
audience, with limited contact between the two.

**Education** -- This strategy builds skills through structured learning
processes. Critical life and social skills include decision making, peer
resistance, coping with stress, problem solving, interpersonal
communication, and systematic and judgmental abilities. There is more
interaction between facilitators and participants than in the
information strategy.

**Alternatives** -- This strategy provides participation in activities
that exclude alcohol and other drugs. The purpose is to meet the needs
filled by alcohol and other drugs with healthy activities, and to
discourage the use of alcohol and drugs through these activities.

**Problem Identification and Referral** -- This strategy aims at
identification of those who have indulged in illegal/age-inappropriate
use of tobacco or alcohol and those individuals who have indulged in the
first use of illicit drugs in order to assess if their behavior can be
reversed through education. It should be noted however, that this
strategy does not include any activity designed to determine if a person
is in need of treatment.

**Community-based Process** -- This strategy provides ongoing networking
activities and technical assistance to community groups or agencies. It
encompasses neighborhood-based, grassroots empowerment models using
action planning and collaborative systems planning.

**Environmental** -- This strategy establishes or changes written and
unwritten community standards, codes, and attitudes, thereby influencing
alcohol and other drug use by the general population.

**Other** -- The six primary prevention strategies have been designed to
encompass nearly all of the prevention activities. However, in the
unusual case an activity does not fit one of the six strategies it may
be classified in the "Other" category.

**[Costs Associated with the Development and Conduct of Random,
Unannounced Tobacco Inspections]{.underline} --** Include aggregate
costs associated with carrying out the administrative aspects of the
requirements such as the development of the sample design and the
conducting of the inspections. Now refer back to Form 4 and look at all
the entries you made on row 2 primary prevention. Use the table below to
indicate how much funding supported each of the six strategies. Enter in
whole dollar amounts. For sources of funds other than the SAPT Block
Grant, report **[only]{.underline}** those funds made available during
the expenditure period identified on Form 4.

**Primary Prevention Expenditures Checklist**

+--------------+-----------------+--------+-------+---------+---------+
|              | **Block Grant   | *      | **St  | **      | **      |
|              | FY 2002**       | *Other | ate** | Local** | Other** |
|              |                 | Fed    |       |         |         |
|              |                 | eral** |       |         |         |
+--------------+-----------------+--------+-------+---------+---------+
| Information  | \$              | \$     | \$    | \$      | \$      |
|              |                 |        |       |         |         |
| D            |                 |        |       |         |         |
| issemination |                 |        |       |         |         |
+--------------+-----------------+--------+-------+---------+---------+
| Education    | \$              | \$     | \$    | \$      | \$      |
+--------------+-----------------+--------+-------+---------+---------+
| Alternatives | \$              | \$     | \$    | \$      | \$      |
+--------------+-----------------+--------+-------+---------+---------+
| Problem      | \$              | \$     | \$    | \$      | \$      |
| Id           |                 |        |       |         |         |
| entification |                 |        |       |         |         |
|              |                 |        |       |         |         |
| & Referral   |                 |        |       |         |         |
+--------------+-----------------+--------+-------+---------+---------+
| Com          | \$              | \$     | \$    | \$      | \$      |
| munity-based |                 |        |       |         |         |
| process      |                 |        |       |         |         |
+--------------+-----------------+--------+-------+---------+---------+
| E            | \$              | \$     | \$    | \$      | \$      |
| nvironmental |                 |        |       |         |         |
+--------------+-----------------+--------+-------+---------+---------+
| Other        | \$              | \$     | \$    | \$      | \$      |
+--------------+-----------------+--------+-------+---------+---------+
| Section      | \$              | \$ \*  | \$ \* | \$ \*   | \$ \*   |
| 1926 -       |                 |        |       |         |         |
| Tobacco      |                 |        |       |         |         |
+--------------+-----------------+--------+-------+---------+---------+
| TOTAL        | \$              | \$     | \$    | \$      | \$      |
+--------------+-----------------+--------+-------+---------+---------+

\*Please list all sources, if possible (e.g., Center for Disease Control
and Prevention block grant, foundations).

**How to report expenditures on substance abuse resource development
activities**

Expenditures on resource development activities may involve the time of
State or sub-State personnel, or other State or sub-State resources.
These activities may also be funded through contracts, grants, or
agreements with other entities. Look at the following definitions to see
if your State made these kinds of expenditures with the **FY 2002 block
grant award** (column A on Form 4). Your State may use different
terminology or a different classification system to describe these kinds
of activities. Just do the best you can in converting your terminology
into these seven categories.

**Planning, coordination, and needs assessment** -- This includes State,
regional, and local personnel salaries prorated for time spent in
planning meetings, data collection, analysis, writing, and travel. It
also includes operating costs such as printing, advertising, and
conducting meetings. Any contracts with community-based organizations or
local governments for planning and coordination fall into this category,
as do needs assessment projects to identify the scope and magnitude of
the problem, resources available, gaps in services, and strategies to
close those gaps.

**Quality assurance** -- This includes activities to assure conformity
to acceptable professional standards and to identify problems that need
to be remedied. These activities may occur at the State, sub-State, or
program level. Sub-State administrative agency contracts to monitor
service providers fall in this category, as do independent peer review
activities.

**Training (post-employment)** -- This includes staff development and
continuing education for personnel employed in local programs as well as
support and coordination agencies, as long as the training relates to
substance abuse services delivery. Typical costs include course fees,
tuition and expense reimbursements to employees, trainer(s) and support
staff salaries, and certification expenditures.

**Education (pre-employment)** -- This includes support for students and
fellows in vocational, undergraduate, graduate, or postgraduate programs
who have not yet begun working in substance abuse programs. Costs might
include scholarship and fellowship stipends, instructor(s) and support
staff salaries, and operating expenses.

**Program development** -- This includes consultation, technical
assistance, and materials support to local providers and planning
groups. Generally these activities are carried out by State and
sub-State level agencies.

**Research and evaluation** -- This includes clinical trials,
demonstration projects to test feasibility and effectiveness of a new
approach, and program performance evaluation. These activities may have
been carried out by the principal agency of the State or an independent
contractor.

**Information systems** -- This includes collecting and analyzing
treatment and prevention data to monitor performance and outcomes. These
activities might be carried out by the principal agency of the State or
an independent contractor.

**Now complete the following checklist:**

[Did your State fund resource development activities from the FY 2002
block grant]{.underline}?

 Yes

 No

If **yes**, show the [actual]{.underline} or [estimated]{.underline}
amounts spent. These amounts may be part of lines 1 through 4 in column
A of Form 4. In describing resource expenditures, you are **not**
limited to line 5 (Administration) funds alone. If you cannot separate
expenditures on treatment resource development from those on primary
prevention resource development, just enter the total amount on the
"Total" line at the right. Enter amounts in whole dollars.

[Treatment]{.underline} [Prevention]{.underline} [Total]{.underline}

 Planning, coordination, \$ \$ \$\_\_\_\_\_\_\_\_\_\_

and needs assessment

 Quality assurance \$ \$ \$\_\_\_\_\_\_\_\_\_\_

 Training (post-employment) \$ \$ \$\_\_\_\_\_\_\_\_\_\_

 Education (pre-employment) \$ \$ \$\_\_\_\_\_\_\_\_\_\_

 Program development \$ \$ \$[\_\_\_\_\_\_\_\_\_\_]{.underline}

 Research and evaluation \$ \$ \$\_\_\_\_\_\_\_\_\_\_

 Information systems \$ \$ \$[\_\_\_\_\_\_\_\_\_\_]{.underline}

TOTAL \$ \$ \$

> Please indicate if expenditures on resource development activities are
> [actual]{.underline} or [estimated]{.underline}.

 Actual  Estimated

**3. Entity inventory** **(Form 6)**

This item documents the activities for which FY 2002 funds were expended
by entity. This information is required by CSAT to meet its obligations
under the Federal Managers Financial Integrity Act of 1982
([See]{.underline} 31 U.S.C. 3512). The item requires completion of the
Substance Abuse Entity Inventory followed by a listing of entities
without an Inventory of Substance Abuse Treatment Services (I-SATS) ID
that received funds from the FY 2002 SAPT Block Grant.

The term "entities" is used to cover State and non-State providers,
sub-recipient agencies and contractors, grantees, and other programs or
entities directly funded by the State. It includes all direct providers
of substance abuse prevention activities and treatment services as well
as those who furnish services to these providers. Examples of the latter
are trainers, technical assistance consultants, system developers, and
evaluators. Expenditures, including grants and contracts of \$25,000 or
less for similar purposes and similar areas, may be aggregated into a
single line in column 1 if these funds are used by the same State
ID/I-SATS ID number. Include only those entities that receive block
grant funds.

Form 6 combines a great deal of important information. It identifies how
and where each entity used FY 2002 block grant funds and how much of the
funding went to alcohol services, drug services, prevention activities,
services for HIV early intervention and services for pregnant women and
women with dependent children.

**Preparing to complete Form 6**

Make a list of all entities that received FY 2002 block grant funds
and/or to which FY 2002 block grant funds have been obligated. Each
entity must have a unique number. You can either number the list
consecutively, starting with 1, **or** use unique State identifier
numbers. It does not matter which entity goes first on the list. If an
entity has an Inventory of Substance Abuse Treatment Services (I-SATS)
ID, place that ID number after the name. If your State funded direct
service providers that have not yet been assigned a number, call the
contractor for the Office of Applied Studies, SAMHSA, Ms. Alicia McCoy
at 703-807-2329 to obtain one or complete the list attached to Form 6
(described immediately before Form 6A). If you are not using WEB-BGAS,
you will need multiple copies of the form. Enter the State's name on
each copy.

**How to complete Form 6**

This form should be filled out in two stages. The first stage involves
completion of columns 1 through 3. These columns record information
about the entity. The second stage involves completion of columns 4
through 9. These columns record information about the use of funds.

Here are detailed instructions for each stage.

**Stage one: Entering entity information (Columns 1 through 3)**

First complete columns 1 through 3 for each entity on your list,
starting with the first one.

**Column 1: Entity number** -- This is the number from the entity list
you assembled in preparing to complete the form.

**Column 2: I-SATS ID** -- If the entity has an I-SATS ID, enter that
number here. Place an "X" in the box if the entity has no I-SATS ID.

**Column 3: Area served** -- This column shows the geographical area
served by the entity and involves coded entries. Enter the code you
assigned for the sub-State area(s) that the entity serves. Each State
may elect how to define its sub-State planning areas. [Please append a
definition of each sub-State planning area by geographic
entity]{.underline}. As an example, if sub-State planning area A
comprises four counties, list the county names; if sub-State planning
area A is a major metropolitan area and sub-State planning area B
comprises the surrounding counties, provide that information. States are
encouraged to keep the number of areas to a minimum; however, [States
must identify at least two sub-State planning areas]{.underline}. These
same areas will be used in the needs assessment required in Section III
of this application.

-   An entity may serve the whole State (Statewide) or an entity may
    serve several areas. For example, entity 1 is a program that serves
    the entire State. When completing column 3 for this entity, enter a
    code of '99.'

-   [When using the electronic WEB Block Grant Application System (WEB
    BGAS), a code of '99' must be entered for any 'Statewide' program.
    No other code will be accepted by program]{.underline}.

When an entity serves more than one sub-State Planning Areas(s) (SPAs),
you will use multiple lines. For example, entity 2 serves two of the
SPAs your State designates. You must complete columns 1-3 in one row for
the first the entity serves. You must then complete columns 1-3 of a
second row for the second SPA the entity serves.

**Stage two: Entering funding information** (Columns 4 through 9)

These columns describe funding to providers and other entities and how
the funding was used for substance abuse prevention activities and
treatment services. They require distributing the funding in various
ways. Remember that you have to fill out all these columns for **every**
line you completed in stage one. If a column is **[not]{.underline}**
applicable to a given line, put a zero in that column. All of the
columns, with the exception of column 5, refer to SAPT Block Grant
funding [only]{.underline}.

**Column 4: SAPT Block Grant** -- Expenditures from the **FY 2002**
block grant award should be entered. Do [not]{.underline} include funds
for administration cost in this column.

**Column 5: State funds** -- Include all State funds spent **during the
12-month State expenditure period you designated on Form 4**. These
funds were reported in column D on Form 4.

>  Columns 6 through 9 refer **only** to the portion of the **FY 2002**
> block grant award that went to either direct or indirect service
> providers, i.e., entities. Do [not]{.underline} include funds spent on
> State staff or administration.

**Column 6: SAPT Block Grant funds for alcohol and drug services** --
Enter the amount of funds from the FY 2002 award for this purpose.
**This includes funds used for alcohol and drug prevention and treatment
activities.** Do [not]{.underline} include funds for administration cost
in this column.

**Column 7: SAPT Block Grant funds for primary prevention** -- Enter the
amount of funds from the FY 2002 award for this purpose. This includes
funds for education and counseling, and for activities designed to
reduce the risk of substance abuse. Do [not]{.underline} include funds
for administration cost in this column.

**Column 8: SAPT Block Grant funds for HIV Early Intervention Services**
-- Enter the amount of funds from the FY 2002 award for this purpose, if
applicable. Include funds for pre-test counseling, testing, post-test
counseling, and the provision of therapeutic measures to diagnose the
extent of deficiency in the immune system to prevent and treat the
deterioration of immune system, and to prevent and treat conditions
arising from the disease. Include the cost of making referrals to other
treatment providers in this item. Do [not]{.underline} include funds for
administration cost in this column.

**Column 9: SAPT Block Grant funds for services for pregnant women and
women with dependent children** -- Enter the amount of funds from the FY
2002 award for this purpose. This includes treatment for pregnant women
and women with dependent children, and while women are in treatment
funds for prenatal care and childcare. Do [not]{.underline} include
funds for administration cost in this column.

Columns 6 through 9 may add up to more than column 4. For example, a
provider may operate an alcohol treatment program targeted toward women.
The FY 2002 block grant funding for this provider would be entered
twice, first in column 6 and again in column 9.

**List attached to Form 6**

Immediately following the Substance Abuse Entity Inventory form, insert
a list of each entity that does **[not]{.underline}** have a I-SATS ID
number and provide the entity's **[name, street address, city/state
(including zip code), and telephone number (including area
code)]{.underline}.** Use the same unique identifying number that you
provided on Form 6 in column 1.

(**[If your State is submitting an electronic application, enter this
list as records in the screens immediately following Form
6]{.underline}**.)

**Prevention strategy report (Form 6A)**

*NOTE: Completion of portions of this form will be optional for a
further three* *years [except for column B]{.underline}. During this
time, SAMHSA would like to continue to work with the States to refine
and finalize this form. SAMHSA is especially interested in developing
common definitions for the elements being reported and identifying data
sources which may be used to provide these data. States are requested to
complete the form as completely as possible (e.g., at least column B and
as much more as possible). Provide any comments that will enhance the
meaningfulness of the information and aid in improving the completeness,
validity and reliability of the data.*

The Prevention Strategy Report requires additional information (in
accordance with section 1929 of the PHS Act) about the primary
prevention activities conducted by the entities listed on Form 6, column
7. It seeks further information on the specific strategies and
activities being funded by the principal agency of the State that
addresses the sub-populations at risk for alcohol, tobacco, and other
drug (ATOD) use/abuse.

**Instructions for completing Form 6A**

This form has three columns. The first column seeks information about
the sub-populations at risk that are being addressed by the State's
primary prevention program; the second column seeks information about
the specific primary prevention strategy(ies) and activities being
employed to address each of these risk categories; and the third column
seeks information about the total number of providers carrying out each
of the activities reported in column B. [States are required only to
complete column B each year and are strongly encouraged to complete the
other 2 columns, where possible. If the State completes optional column
A, it need only report on those risk categories that were considered
appropriate for its primary prevention program and that were addressed
during the reporting year. In completing Column B, the State need only
report on those strategies and activities that were considered
appropriate and that were conducted during the reporting
year]{.underline}.

**Column A: Risk categories**

States are asked to list each of the sub-populations at risk toward
which their primary prevention program is directed. One risk category
should be listed on each line. The risk categories and codes are listed
below. (SAMHSA recognizes that resource limitations may result in a
State's addressing only those risk categories of greatest concern.) For
any risk category not listed below, code the category using codes
beginning with "11" and enter a description on the same line. For
example, if your State uses three risk categories that do not fit into
any of the categories below, enter the code "11" and description of the
category. The second category would be coded as "12" and its description
beside it. The third category would be coded as "13", etc.

01 Children of substance abusers

02 Pregnant women/teens

03 Drop-outs

04 Violent and delinquent behavior

05 Mental health problems

06 Economically disadvantaged

07 Physically disabled

08 Abuse victims

09 Already using substances

10 Homeless and/or runaway youth

11 Other, specify

**Column B**: **Strategy/activity**

This column describes the primary prevention strategy/activity or
strategies and activities used by the principal agency of the State to
address [each]{.underline} of the risk categories identified in column A
and involves coded entries listed below. The definitions for these
strategies have been provided in the block grant regulations and are
repeated in Section III of this Application. If a State employs
strategies not covered by these six categories, please report these
under "Other Strategies."

A State may employ several strategies and activities for each risk
category. For example, it may provide both parenting classes and a
clearinghouse. Each strategy used to address a risk category should be
listed on a separate line.

If you code "Other, specify," enter the description of the type of
strategy/activity on the same line.

The codes for use in column B are:

**Information** **Dissemination**

01 Clearinghouse/information resources centers

02 Resource directories

03 Media campaigns

04 Brochures

05 Radio and TV public service announcements

06 Speaking engagements

07 Health fairs and other health promotion, e.g., conferences, meetings,
seminars

08 Information lines/Hot lines

09 Other, specify

**Education**

11 Parenting and family management

12 Ongoing classroom and/or small group sessions

13 Peer leader/helper programs

14 Education programs for youth groups

15 Mentors

16 Preschool ATOD prevention programs

17 Other, specify

**Alternatives**

21 Drug free dances and parties

22 Youth/adult leadership activities

23 Community drop-in centers

24 Community service activities

25 Outward Bound

26 Recreation activities

27 Other, specify

**Problem Identification and Referral**

31 Employee Assistance Programs

32 Student Assistance Programs

33 Driving while under the influence/driving while intoxicated education
programs

34 Other, specify

**Community-Based Process**

41 Community and volunteer training, e.g., neighborhood action training,
impactor training, staff/officials training

42 Systematic planning

43 Multi-agency coordination and collaboration/coalition

44 Community team-building

45 Accessing services and funding

46 Other, specify

> **Environmental**

51 Promoting the establishment of review of alcohol, tobacco, and drug
use policies in schools

52 Guidance and technical assistance on monitoring enforcement governing
availability and distribution of alcohol, tobacco, and other drug use

53 Modifying alcohol and tobacco advertising practices

54 Product pricing strategies

55 Other, specify

**Other prevention activities**

For any prevention activity not included in the list above, code the
activity using codes beginning with "71" and enter a description on the
same line. For example, if your State uses three unique primary
prevention activities that do not fit into any of the categories above,
enter the code "71" in column B and description of the activity. The
second activity would be coded as "72" and its description would be
entered on a separate line. The third strategy would be coded as "73,"
etc.

**Column C: Providers**

This column records the number of providers performing each of the
activities identified in Column B. Providers are those entities reported
on Form 6 of the application as having expended prevention set-aside
funds.

Enter the total number of providers that employ a specific
strategy/activity to address the prevention needs of a risk category
before proceeding to the next line.

**4. How to complete Forms 7A and 7B**

These items require the completion of the Treatment Utilization Matrix
(Forms 7A and 7B).

Form 7A documents the types and amounts of care purchased Statewide
**during the 12-month State expenditure period you designated on Form
1,** by the principal agency of the State administering the block grant.
Include **all** care purchased with public dollars, regardless of the
source of funds.

**How to Complete Form 7A**

Report the number of service delivery units approved (accredited,
licensed, or deemed status) by the State for each level of service.

Use **column A** to report the number of State approved facilities
(service delivery units) for each level of care and Total.

Use **columns B, E, and H** to report the number of admissions (total
admissions) for each of the respective types of care.

Use **columns C, F, and I** to report the number of persons served
(unduplicated count) for each of the respective types of care.

Use **columns D, G, and J** to report the average cost per person for
each of the respective types of care (total cost, including operating
and capital costs, divided by persons served). Report the range of costs
per person, i.e., the minimum and maximum cost per person.

-   In programs that offer services to both the patient and family
    members or others, count only those who actually have a record and
    receive counseling or treatment services. For example, if a women's
    program provides only day care for patients' children, do not count
    the children.

Your State may not have funded all types of care. If any row is
inapplicable, enter zeroes in the appropriate columns. Enter the
unduplicated total for columns C, F, and I in the row labeled "Total."
Enter the total number of admissions for columns B, E, and H in the row
labeled "Total."

In **column K**, indicate whether or not there was a State-validated
count of these admissions and people served by entering a checkmark on
the left ("yes") or right ("no") side of the column.

-   Did the State base the values reported on Form 7A from a
    client-based system(s) with unique client identifiers?

>  Yes  No

-   Please estimate the percent of reported values that could be
    duplicative %.

**Number Of Persons Served (Unduplicated Count) For Alcohol And Other
Drug Use In State Funded Services (Form 7B)**

Form 7B requires the completion of the number of persons served
(unduplicated count) Statewide for alcohol and other drug use in State
funded services. This form provides a breakout of persons served by age,
gender, race and ethnicity. It also documents the number of clients who
were pregnant. Form 7B describes persons served though care purchased
Statewide by the principal agency of the State administering the block
grant **during the 12-month State expenditure period you designated on
Form 1**. Include **all** care purchased with public dollars, regardless
of the source of funds.

# How to complete Form 7B

This form covers the number of persons served (unduplicated count) who
received care from the principal agency of the State purchased **in the
State expenditure period** designated on Form 1**.**

Report the number of persons served (unduplicated count) for all the
columns and rows. For the "Total" columns and rows, enter the number of
persons served for the total group captured within the cells in these
columns and rows.

The total of columns B through H should equal the total reported in
column A (this total should also equal the sum of columns I and J). The
sum of Form 7B male and female totals should equal the sum of Form 7A,
**Columns C, F, and I** totals. If you enter data in the WEB-BGAS
version of the uniform application, this relationship is automatically
verified.

**Maintenance of Effort (MOE) Tables: (Single State Agency (SSA) MOE, TB
MOE, HIV MOE, and Women's Base).**

**Instructions and Forms for completing Tables I through IV**

**[Table I]{.underline}**

Table I is a Maintenance of Effort (MOE) table tracking substance abuse
funds flowing through the SSA during each State fiscal year (SFY).

-   Enter expenditures for SFYs 2002, 2003, and 2004 in the
    corresponding boxes (B1, B2 and B3) in column B. (The State may,
    with approval from the Secretary, exclude from the calculation
    non-recurring expenditures awarded to the SSA for a specific purpose
    for SFY 2001 and subsequent fiscal years, see below).

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-   Compute the average of the amounts in B1 and B2 by adding the two
    amounts and dividing by 2. Enter the resulting average in Box C2.

The MOE for State fiscal year (SFY) 2004 is met if the amount in Box B3
is greater than or equal to the amount in Box C2 assuming the State
complied with MOE requirements in these previous years.

The State may request an exclusion of certain non-recurring expenditures
for a singular purpose from the calculation of the MOE, provided it
meets CSAT approval based on review of the following information:

Did the State have any non-recurring expenditures for a specific purpose
which were not included in the MOE calculation?

Yes\_\_\_\_ No \_\_\_

If yes, specify the amount \_\_\_\_\_\_\_\_\_\_\_.

Did the State include these funds in previous year MOE calculations?
Yes\_\_\_ No\_\_\_.

Please describe in no more than three paragraphs for what purpose these
funds will be used and attach supporting source documentation in the
appendix (e.g., State legislation, budget act language, memoranda of
understanding).

**Indicate whether the expenditures in Columns (B) and (C) are estimated
or final expenditure figures for the State fiscal years involved.**

**[Table II]{.underline}**

Table II is a MOE table tracking all Statewide, non-Federal funds spent
on Tuberculosis (TB) services to substance abusers in treatment during
each SFY.

> 1\. Enter State funds spent on TB services for SFY 1991 in box A1 of
> Table II (Base).

2\. Enter the [actual]{.underline} or [estimated]{.underline} percent of
these funds that was spent on substance abusers in treatment for SFY
1991 in box B1 of Table II (Base).

> 3\. Divide this percent by 100 to change it to a decimal.
>
> 4\. Multiply the amount in box A1 by the decimal value of the amount
> in box B1. Enter the resulting amount in box C1 of Table II (Base).
>
> 5\. Follow the same procedure for row 2 in Table II (Base) as was done
> in row 1.
>
> 6\. Compute the average of the amounts in boxes C1 and C2. Enter the
> resulting average (MOE Base) in box D2.
>
> 7\. Follow the above procedure (steps 1 through 4) for rows 3 and 4 of
> Table II (Maintenance).

**The TB MOE is met in State fiscal year 2004, if the amount in box C3
is equal to or greater than the amount in box D2 of the top chart.**

**[Tables III A, B, C, and D]{.underline}**

Tables III A, B, C, and D are MOE tables tracking all non-Federal funds
spent on early intervention services for HIV provided to substance
abusers in treatment at the site at which they receive substance abuse
treatment during each SFY.

**[COMPLETE TABLE III A ONLY IF YOUR STATE WAS A DESIGNATED STATE
BEGINNING IN 1993]{.underline}**.

> 1\. Enter State funds spent on early intervention services for HIV for
> SFY1991 and SFY 1992, respectively, in boxes A1 and A2 of the left
> chart.
>
> 2\. Compute the average of the amounts in boxes A1 and A2. Enter the
> resulting average (MOE Base) in box B2.
>
> 3\. Enter State funds spent on early intervention services for HIV for
> State fiscal year 2004 box A3 of the right chart (MAINTENANCE).

**[COMPLETE TABLE III B ONLY IF YOUR STATE WAS A DESIGNATED STATE
BEGINNING IN 1994.]{.underline}**

> 1\. Follow steps 1 and 2 above to complete boxes A1, A2, and B2 of the
> left chart for the SFY 1992 and SFY 1993 (MOE Base).
>
> 2\. Follow step 3 above to complete boxes A3 of the right chart for
> 2004 (MAINTENANCE).

**[COMPLETE TABLE III C ONLY IF YOUR STATE WAS A DESIGNATED STATE
BEGINNING IN 1995.]{.underline}**

> 1\. Follow steps 1 and 2 above to complete boxes A1, A2, and B2 of the
> left chart for the SFY 1993 and SFY 1994 (MOE Base).
>
> 2\. Follow step 3 above to complete boxes A3 of the right chart for
> SFY 2004 (MAINTENANCE).

**The HIV MOE is met in State fiscal year 2004, if the amount in box A3
in the right chart (MAINTENANCE), is equal to or greater than the amount
in box B2 of the corresponding left chart (MOE Base).**

**[COMPLETE TABLE III D ONLY IF YOUR STATE WAS A DESIGNATED STATE
BEGINNING IN 1998.]{.underline}**

> 1\. Follow steps 1 and 2 above to complete boxes A1, A2, and B2 of the
> left chart for the SFY 1996 and SFY 1997 (MOE Base).
>
> 2\. Follow step 3 above to complete boxes A3 of the right chart for
> SFY 2004 (MAINTENANCE).

**The HIV MOE is met in State fiscal year 2004 if the amount in box A4
in the right chart (MAINTENANCE), is equal to or greater than the amount
in box B2 of the corresponding left chart (MOE Base).**

**[Table IV]{.underline}**

Table IV tracks the total (block grant and State) expenditures for
services to substance using pregnant women and women with dependent
children during each fiscal year.

> 1\. For 1994, enter the base in column A.

2\. For Federal fiscal year 1995 and subsequent fiscal years the States
must maintain expenditures for services for pregnant women and women
with dependent children at a level that is not less than the FY 1994
expenditures; however, the expenditures may be any combination of SAPT
Block Grant and State general revenue (including the State's
contribution to Medicaid). Report State Fiscal Years 2002, 2003, and
2004 expenditures in column B.

**Table I**

Total Single State Agency (SSA) Expenditures for Substance Abuse

+---------------------+---------------------+-------------------------+
| Period              | Expenditures        | [B1 (2002) + B2 (2003   |
|                     |                     | )]{.underline}          |
| \(A\)               | \(B\)               |                         |
|                     |                     | 2                       |
|                     |                     |                         |
|                     |                     | \(C\)                   |
+---------------------+---------------------+-------------------------+
| SFY 2002            |                     |                         |
|                     |                     |                         |
| \(1\)               |                     |                         |
+---------------------+---------------------+-------------------------+
| SFY 2003            |                     |                         |
|                     |                     |                         |
| \(2\)               |                     |                         |
+---------------------+---------------------+-------------------------+
| SFY 2004            |                     |                         |
|                     |                     |                         |
| \(3\)               |                     |                         |
+---------------------+---------------------+-------------------------+

Are the expenditure amounts reported in Columns B and C "actual" or
"estimated" expenditures for the State fiscal years involved?

Column B Actual Expenditures Yes No

Column C Actual Expenditures Yes No

If No, please indicate when "actual" expenditure data will be submitted
to SAMHSA:

[mm/dd/yyyy]{.underline}

The State may request an exclusion from the calculation of the MOE
certain non-recurring expenditures for a singular purpose, provided the
State can demonstrate that the State's exclusion of certain funds
request is consistent with the following guidance:

In order for SAMHSA to approve a request from a State to have excluded
from the aggregate State expenditures funds appropriated by the State
legislature to the principal agency for authorized activities which are
of a non-recurring nature and for a specific purpose, the following is
necessary:

1\. The State shall request the exclusion separately from the
application;

2\. The request shall be signed by the State's Chief Executive Officer
or by an individual authorized to apply for the SAPT or CMHS Block Grant
on behalf of the Chief Executive Officer. SAMHSA will consider such
requests for funds expended after the date of enactment of Public Law
106-310, October 17, 2000, in the first year for which additional funds
are being added to the budget for such activities;

3\. The State shall provide documentation that supports its position
that the funds were appropriated by the State legislature for authorized
activities which are of a non-recurring nature and for a specific
purpose, indicates the length of time the project is expected to last in
years and months, and affirms that these expenditures would be in
addition to funds needed to otherwise meet the State's maintenance of
effort requirement for the year for which it is applying for exclusion;
and

4\. The Administrator of SAMHSA agrees that the criteria for exclusion
have been met.

Did the State have any non-recurring expenditures for a specific purpose
that were not included in the MOE calculation?

Yes\_\_\_\_ No\_\_\_

If yes, specify the amount: \$ \_\_\_\_\_\_\_\_\_\_\_\_

Did the State include these funds in previous year MOE calculations?
Yes\_\_\_\_\_ No\_\_\_\_\_

**Table II (BASE)**

Statewide Non-Federal Expenditures for Tuberculosis Services to
Substance Abusers in Treatment

+--------+-----------+----------------+-----------------+------------+
| Period | Total of  | \% of TB       | Total State     | Average of |
|        | All State | Expenditures   | Funds Spent on  |            |
|        | Funds     | Spent on       | Clients who     | Column C1  |
|        | Spent on  | Clients who    | were Substance  | and C2     |
|        | TB        | were Substance | Abusers in      |            |
|        | Services  | Abusers in     | Treatment (AxB) | [C1 +      |
|        |           | Treatment      |                 | C2]{.      |
|        | \(A\)     |                | \(C\)           | underline} |
|        |           | \(B\)          |                 |            |
|        |           |                |                 | 2          |
|        |           |                |                 |            |
|        |           |                |                 | (MOE BASE) |
|        |           |                |                 |            |
|        |           |                |                 | \(D\)      |
+--------+-----------+----------------+-----------------+------------+
| SFY    |           |                |                 |            |
| 1991   |           |                |                 |            |
|        |           |                |                 |            |
| \(1\)  |           |                |                 |            |
+--------+-----------+----------------+-----------------+------------+
| SFY    |           |                |                 |            |
| 1992   |           |                |                 |            |
|        |           |                |                 |            |
| \(2\)  |           |                |                 |            |
+--------+-----------+----------------+-----------------+------------+

**Table II (MAINTENANCE)**

Statewide Non-Federal Expenditures for Tuberculosis Services to
Substance Abusers in Treatment

+--------------+----------------+------------------+------------------+
| Period       | Total of All   | \% of TB         | Total State      |
|              | State Funds    | Expenditures     | Funds Spent on   |
|              | Spent on TB    | Spent on Clients | Clients who were |
|              | Services       | who were         | Substance        |
|              |                | Substance        | Abusers in       |
|              | \(A\)          | Abusers in       | Treatment (AxB)  |
|              |                | Treatment        |                  |
|              |                |                  | \(C\)            |
|              |                | \(B\)            |                  |
+--------------+----------------+------------------+------------------+
| SFY 2004     |                |                  |                  |
|              |                |                  |                  |
| \(3\)        |                |                  |                  |
+--------------+----------------+------------------+------------------+

**Table III A**

Statewide Non-Federal Expenditures for HIV Early Intervention Services
to Substance Abusers in Treatment (**Table III A**)

**USE THIS TABLE (III A) IF YOUR STATE WAS A DESIGNATED STATE BEGINNING
IN 1993.**

(BASE) (MAINTENANCE)

+-------+--------------+------------+--------+----------+------------+
| P     | Total of All | Average of |        | Period   | Total of   |
| eriod | State Funds  | Columns    |        |          | All State  |
|       | Spent on     |            |        |          | Funds      |
|       | Early        | A1 and A2  |        |          | Spent on   |
|       | Intervention |            |        |          | Early      |
|       | Services for | [A1+A2]{.  |        |          | In         |
|       | HIV          | underline} |        |          | tervention |
|       |              |            |        |          | Services   |
|       | \(A\)        | 2          |        |          | for HIV    |
|       |              |            |        |          |            |
|       |              | (**MOE     |        |          | \(A\)      |
|       |              | Base**)    |        |          |            |
|       |              |            |        |          |            |
|       |              | \(B\)      |        |          |            |
+-------+--------------+------------+--------+----------+------------+
| SFY   |              |            |        |          |            |
| 1991  |              |            |        |          |            |
|       |              |            |        |          |            |
| \(1\) |              |            |        |          |            |
+-------+--------------+------------+--------+----------+------------+
| SFY   |              |            |        | SFY 2004 |            |
| 1992  |              |            |        |          |            |
|       |              |            |        | \(3\)    |            |
| \(2\) |              |            |        |          |            |
+-------+--------------+------------+--------+----------+------------+

**Table III B**

Statewide Non-Federal Expenditures for HIV Early Intervention Services
to Substance Abusers in Treatment

**USE THIS TABLE (III B) IF YOUR STATE IS A DESIGNATED STATE BEGINNING
IN 1994.**

(BASE) (MAINTENANCE)

+-------+------------+------------+------+---------+-----------------+
| P     | Total of   | Average of |      | Period  | Total of All    |
| eriod | All State  | Columns    |      |         | State Funds     |
|       | Funds      |            |      |         | Spent on Early  |
|       | Spent on   | A1 and A2  |      |         | Intervention    |
|       | Early      |            |      |         | Services for    |
|       | In         | [A1+A2]{.  |      |         | HIV             |
|       | tervention | underline} |      |         |                 |
|       | Services   |            |      |         | \(A\)           |
|       | for HIV    | 2          |      |         |                 |
|       |            |            |      |         |                 |
|       | \(A\)      | (**MOE     |      |         |                 |
|       |            | Base**)    |      |         |                 |
|       |            |            |      |         |                 |
|       |            | \(B\)      |      |         |                 |
+-------+------------+------------+------+---------+-----------------+
| SFY   |            |            |      |         |                 |
| 1992  |            |            |      |         |                 |
|       |            |            |      |         |                 |
| \(1\) |            |            |      |         |                 |
+-------+------------+------------+------+---------+-----------------+
| SFY   |            |            |      | SFY     |                 |
| 1993  |            |            |      | 2004    |                 |
|       |            |            |      |         |                 |
| \(2\) |            |            |      | \(3\)   |                 |
+-------+------------+------------+------+---------+-----------------+

**Table III C**

Statewide Non-Federal Expenditures for HIV Early Intervention Services
to Substance Abusers in Treatment (**Table III C**)

**USE THIS TABLE (III C) IF YOUR STATE IS A DESIGNATED STATE BEGINNING
IN 1995**

(BASE) (MAINTENANCE)

+-----------+-----------+-------------+-----+---------+--------------+
| Period    | Total of  | Average of  |     | Period  | Total of All |
|           | All State | Columns A1  |     |         | State Funds  |
|           | Funds     | and A2      |     |         | Spent on     |
|           | Spent on  |             |     |         | Early        |
|           | Early     | [A1+A2]{    |     |         | Intervention |
|           | Int       | .underline} |     |         | Services for |
|           | ervention |             |     |         | HIV          |
|           | Services  | 2           |     |         |              |
|           | for HIV   |             |     |         | \(A\)        |
|           |           | (**MOE      |     |         |              |
|           | \(A\)     | Base**)     |     |         |              |
|           |           |             |     |         |              |
|           |           | \(B\)       |     |         |              |
+-----------+-----------+-------------+-----+---------+--------------+
| SFY 1993  |           |             |     |         |              |
|           |           |             |     |         |              |
| \(1\)     |           |             |     |         |              |
+-----------+-----------+-------------+-----+---------+--------------+
| SFY 1994  |           |             |     | SFY     |              |
|           |           |             |     | 2004    |              |
| \(2\)     |           |             |     |         |              |
|           |           |             |     | \(3\)   |              |
+-----------+-----------+-------------+-----+---------+--------------+

**Table III D**

Statewide Non-Federal Expenditures for HIV Early Intervention Services
to Substance Abusers in Treatment (**Table III D**)

**USE THIS TABLE (III D) IF YOUR STATE IS A DESIGNATED STATE BEGINNING
IN 1998**

(BASE) (MAINTENANCE)

+-------+----------------+---------+------+-----------+--------------+
| P     | Total of All   | Average |      | Period    | Total of All |
| eriod | State Funds    | of      |      |           | State Funds  |
|       | Spent on Early | Columns |      |           | Spent on     |
|       | Intervention   | A1 and  |      |           | Early        |
|       | Services for   | A2      |      |           | Intervention |
|       | HIV            |         |      |           | Services for |
|       |                | [A1+A   |      |           | HIV          |
|       | \(A\)          | 2]{.und |      |           |              |
|       |                | erline} |      |           | \(A\)        |
|       |                |         |      |           |              |
|       |                | 2       |      |           |              |
|       |                |         |      |           |              |
|       |                | (**MOE  |      |           |              |
|       |                | Base**) |      |           |              |
|       |                |         |      |           |              |
|       |                | \(B\)   |      |           |              |
+-------+----------------+---------+------+-----------+--------------+
| SFY   |                |         |      |           |              |
| 1996  |                |         |      |           |              |
|       |                |         |      |           |              |
| \(1\) |                |         |      |           |              |
+-------+----------------+---------+------+-----------+--------------+
| SFY   |                |         |      | SFY 2004  |              |
| 1997  |                |         |      |           |              |
|       |                |         |      | \(3\)     |              |
| \(2\) |                |         |      |           |              |
+-------+----------------+---------+------+-----------+--------------+

**Table IV (MAINTENANCE)**

Expenditures for Services to Pregnant Women

and Women with Dependent Children

**SECTION III: STATE PLAN -- INTENDED USE OF FY 2005**

**SUBSTANCE ABUSE PREVENTION AND TREATMENT**

**BLOCK GRANT FUNDS**

This section describes how the State will use the FY 2005 SAPT Block
Grant award. The following is an overview of its information
requirements:

  ------------- ------------------------------------ ----------- --------------------------
  **Item**                                                       **What you need to
                                                                 submit**

  (See Section                                                   
  II for                                                         
  narratives of                                                  
  intended                                                       
  goals,                                                         
  objectives,                                                    
  activities)                                                    

  1\.           Planning                             Narrative   
                                                     and         
                                                     checklist   

  2\.           Needs assessment summary             Form 8 plus 
                                                     narrative   

  3\.           Needs by age, sex, and               Form 9      
                race/ethnicity                                   

  4\.           Intended use plan                    Form 11     

  5\.           Treatment capacity                   Form 12     

  6\.           Purchasing services                  Checklist   

  7\.           Program performance monitoring       Checklist   
  ------------- ------------------------------------ ----------- --------------------------

**1. Planning**

This item addresses compliance of the State's planning procedures with
several statutory requirements. It requires completion of narratives and
a checklist.

These are the statutory requirements:

-   42 U.S.C. 300x-29 requires the State to submit a statewide
    assessment of need for

> both treatment and prevention.

-   42 U.S.C. 300x-51 requires the State to make the State plan public
    in such a

> manner as to facilitate public comment from any person during the
> development
>
> of the plan.

In a narrative of **up to three pages**, describe how your State carries
out sub-State area planning and determines which areas have the highest
incidence, prevalence, and greatest need. Include a definition of your
State's sub-State planning areas. Identify what data is collected, how
it is collected, and how it is used in making these decisions. If there
is a State, regional, or local advisory council, describe their
composition and their role in the planning process. Describe the
monitoring process the State will use to assure that funded programs
serve communities with the highest prevalence and need.

In a narrative of **up to two pages**, describe the process your State
used to facilitate public comment in developing the State's plan and its
FY 2005 application for SAPT Block Grant funds.

Use the following checklist to indicate the criteria your State will use
in deciding how to allocate FY 2005 block grant funds. Mark all criteria
that apply. Indicate the priority of the criteria by placing numbers in
the boxes. For example, if the most important criterion is "incidence
and prevalence levels," put a "1" in the box beside that option. If two
or more criteria are equal, assign them the same number.

 Population levels (Specify
formula:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

 Incidence and prevalence levels

 Problem levels as estimated by alcohol/drug-related crime statistics

 Problem levels as estimated by alcohol/drug-related health statistics

 Problem levels as estimated by social indicator data

 Problem levels as estimated by expert opinion

 Resource levels as determined by (specify method) .

 Size of gaps between resources (as measured by) and needs (as
estimated by).

 Other (specify):

**2. Needs assessment summary**

This item involves completion of a Treatment Needs Assessment Summary
Matrix (Form 8) and a narrative explaining how the State arrived at the
numbers entered on the form, the biases of the data, and how the State
intends to improve the reliability and validity of its data. This
information is required by statute and regulation ([See]{.underline} 42
U.S.C. 300x-29 and 45 C.F.R. 96.133).

**How to complete the Treatment Needs Assessment Summary Matrix (Form
8)**

Before you begin entering numbers, look at columns 6 and 7. It is the
intent of Congress to target funding to areas severely impacted by
substance use and trade. There are various ways to measure both the
prevalence of substance-related criminal activity and the incidence of
communicable diseases. With input from the States, CSAT has designated
two indices for **column 6** (Prevalence of substance-related criminal
activity). These indices are:

-   number of DWI (driving while intoxicated) arrests

-   number of drug-related arrests

The time period on which you report in this column is the **last
calendar year for which you have the data**. In addition, you may use a
third index of your choice for this column. If you choose to do so,
write your index in the blank space in column 6C. If you choose not to
enter a third index, cross out column 6C.

With input from the States, CSAT has designated three indices for
**column 7** (Incidence of communicable diseases). These indices are:

-   number of cases of Hepatitis B per 100,000 population

-   number of cases of AIDS per 100,000 population

-   number of cases of Tuberculosis per 100,000 population

Before you begin to enter data, fill in the box over column 6 indicating
the time period covered by the entries you will make in that column.

**Following are instructions for completing each column:**

**Column 1: Sub-State planning area** -- Enter the name of the sub-State
planning area.

**Column 2: Total population** -- Enter the total population of the
sub-State planning area.

**Column 3: Total population in need** -- Enter on the **left** side (A)
the area's total population in need of substance abuse treatment
services, including those already receiving treatment. Enter on the
**right** side (B) those who would seek treatment but are not currently
being served.

**Column 4: Number of IVDUs in need** -- Enter on the **left** side (A)
the area's total number of IVDUs in need, including those in treatment.
Enter on the **right** side (B) those who would seek treatment but are
not currently being served.

**Column 5: Number of women in need** -- Enter on the **left** side (A)
the area's total number of women in need of substance abuse services,
including those in treatment. Enter on the **right** side (B) those who
would seek it but are not currently being served.

**Column 6: Prevalence of substance-related criminal activity** -- Using
the indices provided and the one you may have selected and written in,
enter the appropriate numbers.

**Column 7: Incidence of communicable diseases** -- Using the indices
provided, enter the appropriate numbers. Do not enter data as fractions.
For example, if there are 40 cases per 100,000 population, write "40"
rather than "40/100,000."

**How your State determined the numbers for the matrix**

Under 42 U.S.C. 300x-29 and 45 C.F.R. 96.133, States are required to
submit annually a needs assessment. This requirement is not contingent
on the receipt of Federal needs assessment resources. States are
required to use the best available data. Using **up to three pages**,
explain what methods your State used to estimate the numbers of people
in need of substance abuse treatment services, the biases of the data,
and how the State intends to improve the reliability and validity of the
data. Also indicate the sources of data used in making these estimates.
In addition, provide any necessary explanation of the way your State
records data or interprets the indices in columns 6 and 7.

**3.** **Needs by age, sex, and race/ethnicity (Form 9).**

This item requires completion of one worksheet for treatment (Form 9).
The form is self-explanatory, distributing the populations by age, sex,
and race-ethnicity. The total of columns B through H should equal the
total reported in column A (this total should also equal the sum of
columns I and J).

**4. Intended use plan** **(Form 11)**

**This item requires the completion of the Intended Use Plan (Form
11)**. The form is similar to the Substance Abuse State Agency Spending
Report (Form 4) that you completed in Section II of the application.

 Row 1: Total expenditures for substance abuse treatment and
rehabilitation.

Instructions for columns A through F: Remember to enter **only** those
funds to be spent by the agency administering the FY 2005 SAPT Block
Grant and to enter figures in whole dollar amounts.

 Most States report that they use the full 24-month period to spend
block grant funds. The intent is to determine how much funding from
other sources is available to the principal agency of the State for
substance abuse prevention and treatment services during the same
period. Even if your State plans to spend the FY 2005 award in less than
24 months, report for the full 24-month period in columns B through F.

**Column A: FY 2005 SAPT Block Grant** -- Enter the amounts of FY 2005
block grant funds your State plans to spend on each activity. If you do
not know how much money your State will receive, base your entries on
the amount of your prior FY award.

**Column B: Medicaid** -- Base your entries on an **estimate** of
Medicaid funds available for the **24-month period in which your State
is permitted to spend the prior FY block grant award**.

**Column C: Other Federal funds** -- Base your entries on an
**estimate** of other Federal funds available for the **24-month period
in which your State is permitted to spend the prior FY block grant
award**.

**Column D: State funds** -- Base your entries on an **estimate** of
State funds available for the **24-month period in which your State is
permitted to spend the prior FY block grant award**.

**Column E: Local funds** -- Base your entries on an **estimate** of
local funds available for the **24-month period in which your State is
permitted to spend the prior FY block grant award**.

**Column F: Other** -- Base your entries on an **estimate** of other
funds available for the **24-month period in which your State is
permitted to spend the prior FY block grant award**. Definitions of the
funding sources in columns B through F were provided in the instructions
for Form 04 in Section II of this application.

**Detailing planned expenditures on primary prevention (Row 2) of Form
11**

Primary prevention activities are those directed [at individuals who do
not require treatment for substance abuse]{.underline}. In implementing
the comprehensive primary prevention program, the State shall use a
variety of strategies including but not limited to the following. If a
State employs strategies not covered by these six categories, please
report them under "Other" in a separate row for each one. PLEASE NOTE
CATEGORY FOR REPORTING COSTS ASSOCIATED WITH IMPLEMENTING SECTION
1926--TOBACCO.

(1) [Information Dissemination]{.underline}: This strategy provides
    awareness and knowledge of the nature and extent of alcohol, tobacco
    and drug use, abuse and addiction and their effects on individuals,
    families and communities. It also provides knowledge and awareness
    of available prevention programs and services. Information
    dissemination is characterized by one-way communication from the
    source to the audience, with limited contact between the two.
    Examples of activities conducted and methods used for this strategy
    include (but are not limited to) the following:

\(i\) Clearinghouse/information resource center(s);

\(ii\) Resource directories;

\(iii\) Media campaigns;

\(iv\) Brochures;

\(v\) Radio/TV public service announcements;

> \(vi\) Speaking engagements;

\(vii\) Health fairs/health promotion; and

\(viii\) Information line.

> \(2\) [Education]{.underline}: This strategy involves two-way
> communication and is distinguished from the Information Dissemination
> strategy by the fact that interaction between the educator/facilitator
> and the participants is the basis of its activities. Activities under
> this strategy aim to affect critical life and social skills, including
> decision-making, refusal skills, critical analysis (e.g., of media
> messages) and systematic judgment abilities. Examples of activities
> conducted and methods used for this strategy include (but are not
> limited to) the following:

\(i\) Classroom and/or small group sessions (all ages);

\(ii\) Parenting and family management classes;

\(iii\) Peer leader/helper programs;

\(iv\) Education programs for youth groups; and

\(v\) Children of substance abusers groups.

> \(3\) [Alternatives]{.underline}: This strategy provides for the
> participation of target populations in activities that exclude
> alcohol, tobacco and other drug use. The assumption is that
> constructive and healthy activities offset the attraction to, or
> otherwise meet the needs usually filled by alcohol, tobacco and other
> drugs and would, therefore, minimize or obviate resort to the latter.
> Examples of activities conducted and methods used for this strategy
> include (but are not limited to) the following:

\(i\) Drug free dances and parties;

\(ii\) Youth/adult leadership activities;

\(iii\) Community drop-in centers; and

> \(iv\) Community service activities.
>
> \(4\) [Problem Identification and Referral]{.underline}: This strategy
> aims at identification of those who have indulged in
> illegal/age-inappropriate use of tobacco or alcohol and those
> individuals who have indulged in the first use of illicit drugs in
> order to assess if their behavior can be reversed through education.
> It should be noted, however, that this strategy does not include any
> activity designed to determine if a person is in need of treatment.
> Examples of activities conducted and methods used for this strategy
> include (but are not limited to) the following:

\(i\) Employee assistance programs;

\(ii\) Student assistance programs; and

\(iii\) Driving while under the influence/driving while intoxicated
education

programs.

> \(5\) [Community-Based Process]{.underline}: This strategy aims to
> enhance the ability of the community to more effectively provide
> prevention and treatment services for alcohol, tobacco and drug abuse
> disorders. Activities in this strategy include organizing, planning,
> enhancing efficiency and effectiveness of services implementation,
> inter-agency collaboration, coalition building and networking.
> Examples of activities conducted and methods used for this strategy
> include (but are not limited to) the following:
>
> \(i\) Community and volunteer training, e.g., neighborhood action
> training,
>
> training of key people in the system, staff/officials training;

\(ii\) Systematic planning;

\(iii\) Multi-agency coordination and collaboration;

\(iv\) Accessing services and funding; and

(v) Community team-building.

> \(6\) [Environmental]{.underline}: This strategy establishes or
> changes written and unwritten community standards, codes and
> attitudes, thereby influencing incidence and prevalence of the abuse
> of alcohol, tobacco and other drugs used in the general population.
> This strategy is divided into two subcategories to permit distinction
> between activities which center on legal and regulatory initiatives
> and those that relate to the service and action-oriented initiatives.
> Examples of activities conducted and methods used for this strategy
> shall include (but not be limited to) the following:
>
> \(i\) Promoting the establishment of review of alcohol, tobacco and
> drug use
>
> policies in schools;
>
> \(ii\) Technical assistance to communities to maximize local
> enforcement procedures governing availability and distribution of
> alcohol, tobacco, and other drug use;
>
> \(iii\) Modifying alcohol and tobacco advertising practices; and

\(iv\) Product pricing strategies.

(7) [Other]{.underline}: The six primary prevention strategies have been
    designed to encompass nearly all of the prevention activities.
    However, in the unusual case an activity does not fit one of the six
    strategies it may be classified in the "Other" category.

**[Section 1926 - Tobacco]{.underline}**

> \(8\) [Costs Associated with the Development and Conduct of Random,
> Unannounced Tobacco Inspections-]{.underline}include aggregate costs
> associated with carrying out the administrative aspects of the
> requirements such as the development of the sample design and the
> conducting of the inspections.

**Primary Prevention Planned Expenditures Checklist**

Estimated data are acceptable in this checklist.

Block Grant Other

[FY 2005]{.underline} [Federal]{.underline} [State]{.underline}
[Local]{.underline} [Other]{.underline}

 Information

Dissemination \$ \$ \$ \$ \$\_\_\_\_\_

 Education \$ \$ \$ \$ \$\_\_\_\_\_

 Alternatives \$ \$ \$ \$ \$\_\_\_\_\_

 Problem

Identification

and Referral \$ \$ \$ \$ \$\_\_\_\_\_

 Community-

based Process \$ \$ \$ \$ \$\_\_\_\_\_

 Environmental \$ \$ \$ \$ \$\_\_\_\_\_

 Other \$ \$ \$ \$ \$\_\_\_\_\_

 Section 1926- \$ \$ \* \$ \* \$ \* \$\_\_\_\_\_

Tobacco

TOTAL \$ \$ \$ \$ \$

\*Please list all sources, if possible (e.g., Center for Disease Control
and Prevention block grant, foundations).

**How to report planned expenditures on substance abuse resource
development activities**

Your State may plan to spend FY 2005 block grant funds on substance
abuse resource development activities. These kinds of activities were
described in Section II. Complete the following checklist:

Does your State plan to fund resource development activities with FY
2005 funds?

 Yes

 No

If **yes**, show the **estimated** amounts that will be spent in the
table below:

[Treatment]{.underline} [Prevention]{.underline} [Total]{.underline}

 Planning, coordination, \$ \$ \$\_\_\_\_\_

and needs assessment

 Quality assurance \$ \$ \$\_\_\_\_\_

 Training (post-employment) \$ \$ \$\_\_\_\_\_

 Education (pre-employment) \$ \$ \$\_\_\_\_\_

 Program development \$ \$ \$\_\_\_\_\_

 Research and evaluation \$ \$ \$\_\_\_\_\_

 Information systems \$ \$ \$\_\_\_\_\_

TOTAL \$ \$ \$

Remember that resource development expenditures are not limited to row
5, Form 11 (Administration). You may plan resource development
expenditures from rows 1 through 5.

**5. Treatment Capacity Matrix (Form 12)**

This involves completion of the Treatment Capacity Matrix (Form 12). It
is identical to Form 7A, except that you enter information about **the
24-month period during which your principal agency of the State is
permitted to spend the FY 2005 block grant award**. This is the same
period covered on the Intended Use Plan (Form 11), and you have already
estimated how much money the principal agency of the State will obligate
and spend. The instructions for completing the form are the same as
those for Form 7A.

**6. Purchasing services**

This item requires completing two checklists.

There are many methods the State can use to purchase substance abuse
services. Use the following checklist to describe how your State will
purchase services with the FY 2005 block grant award. Indicate the
proportion of funding that is expended through the applicable
procurement mechanism. The total for these categories should equal 100
percent.

-   Competitive grants Percent of Expense\_\_\_\_\_

-   Competitive contracts Percent of Expense\_\_\_\_\_

-   Non-competitive grants Percent of Expense\_\_\_\_\_

-   Non-competitive contracts Percent of Expense\_\_\_\_\_

```{=html}
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-   Statutory or regulatory allocation to Percent of Expense\_\_\_\_\_

> governmental agencies serving as
>
> umbrella agencies that purchase or
>
> directly operate services

-   Other Percent of Expense\_\_\_\_\_

> 100%

-   According to county or Percent of Expense\_\_\_\_\_

> regional priorities

There are also alternative ways a State can decide how much it will pay
for services. Use the following checklist to describe how your State
pays for services. Complete any that apply. In addressing a State's
allocation of resources through various payment methods, a State may
choose to report either the proportion of expenditures or proportion of
clients served through these payment methods. Estimated proportions are
acceptable.

 Line item program budget Percent of Clients Served\_\_\_\_\_

Percent of Expenditures\_\_\_\_\_\_

 Price per slot Percent of Clients Served\_\_\_\_\_

Percent of Expenditures\_\_\_\_\_\_

Rate: Type of slot:

Rate: Type of slot:

Rate: Type of slot:

 Price per unit of service Percent of Clients Served\_\_\_\_\_

Percent of Expenditures\_\_\_\_\_\_

Unit: Rate:

Unit: Rate:

Unit: Rate:

 Per capita allocation (Formula): Percent of Clients Served\_\_\_\_\_

Percent of Expenditures\_\_\_\_\_

 Price per episode of care: Percent of Clients Served\_\_\_\_\_

Percent of Expenditures\_\_\_\_\_

Rate: Diagnostic group:

Rate: Diagnostic group:

Rate: Diagnostic group

**7. Program performance monitoring**

The purpose of this item is to document how the principal agency of the
State will monitor and evaluate the performance of substance abuse
service providers that receive State and/or block grant funds. Use the
following checklist to indicate what methods your State uses. Check all
that apply. When you are asked for frequency in the items below, use the
following choices:

-   monthly

-   quarterly

-   semi-annually

-   annually

-   every two years

 On-site inspections

Frequency for treatment: ( )

Frequency for prevention: ( )

 Activity reports

Frequency for treatment: ( )

Frequency for prevention: ( )

 Management information system

 Patient/participant data reporting system

Frequency for treatment: ( )

Frequency for prevention: ( )

 Performance contracts

 Cost reports

 Independent peer review

 Licensure standards - programs and facilities

Frequency for treatment: ( )

Frequency for prevention: ( )

 Licensure standards - personnel

Frequency for treatment: ( )

Frequency for prevention: ( )

 Other (Specify): .

**SECTION IV-A**

**VOLUNTARY TREATMENT PERFORMANCE MEASURES**

**INSTRUCTIONS**

**[TREATMENT MEASURES]{.underline}**

**Data is requested on the following forms**:

Form T1 -- Employment Status

Form T2 -- Living Status

Form T3 -- Criminal Justice Involvement

Form T4 -- Alcohol Use

Form T5 -- Other Drug Use

Form T6 -- Infectious Diseases

Form T7 -- Social Support of Recovery

Form T8 - Retention

**[GENERAL INSTRUCTIONS FOR VOLUNTARY FORMS T1-T8]{.underline}:**

The following set of instructions and optional forms are available for
States to complete **on a voluntary basis**. It is understood that, at
the current time, not all States have the infrastructure in place that
supports the reporting of such data. By participating on a voluntary
basis, States can communicate their current capacity to report on the
proposed SAPTBG supported program performance measures and will thus
help inform future activities leading towards full implementation of the
Performance Partnership Grant Program.

1.  Include [all]{.underline} "Primary Clients" who received services
    from treatment programs that received some or all of their funding
    from the Substance Abuse Prevention and Treatment Block Grant. Do
    [not]{.underline} include family members or other persons
    collaterally involved in the Clients' treatment. Include
    [only]{.underline} persons actually admitted to treatment, excluding
    those who received detoxification, outreach, early intervention or
    assessment/Central Intake services but who did not enter treatment.
    A State may wish to report on specific modalities or populations
    separately such as outpatient, residential and opiate replacement
    therapy or treatment completers versus non-completers. The State is
    asked to clearly identify how and why such distinctions are made.
    The State should discuss how it addressed tracking clients receiving
    opiate replacement therapy/pharmacotherapy in their State and
    provide a description in the State Description of Data Collection
    form.

2.  Report data for the most recent State Fiscal Year for which the data
    are available at the time the application is submitted. In no case
    should the reporting year be earlier than the year for which the
    State is reporting SAPT Block Grant expenditures in the application
    being submitted. Indicate the State Fiscal Year chosen for reporting
    in the appropriate place on the form.

3.  Report data on all clients who have a discharge record in the
    reporting year. All clients with treatment periods that ended in the
    reporting year (i.e., clients who did not receive subsequent
    treatment in 30 days) should have a discharge record.

4.  The State should discuss how it addressed tracking clients receiving
    opiate replacement therapy/pharmacotherapy in their State and
    provide a description in the State Description of Data Collection
    form. Persons receiving pharmacotherapy using methadone may be
    included in the State report of client data or may be reported
    separately.

5.  Please complete each form if possible.

6.  Forms T1-T8 report percentage point changes in the indicator areas
    that have occurred between admission and discharge based on
    information collected at those data collection points. If possible,
    the State should report based on Treatment Episode. In Episode based
    reporting, admission is defined as occurring on the first date of
    service in a program/service delivery unit prior to which no
    services have been received from any program/service delivery unit
    for 30 days. Discharge is defined as occurring on the last date on
    which the client received service from a program/service delivery
    unit, subsequent to which the client received no services from any
    program/service delivery unit for 30 days. For example, a client may
    present for detoxification 29 days after being discharged from an
    intensive outpatient program. If possible, that client's treatment
    in detoxification and subsequent levels of care, if any, should be
    linked to the prior service(s) record(s) up to the point where a
    client had an uninterrupted 30 day period in which no services were
    received. If a client presented for treatment 32 days after being
    discharged from a previous treatment service, a new episode of care
    would begin.

> If a State is unable to report on an episode basis, it should report
> the basis it has used for producing the reported data. For example,
> the State may only be able to report data based on Modalities/Levels
> of Care. The State should also discuss the specific approach used to
> define admission and discharge within this framework.

7.  For each table, please respond to the questions related to data
    source, e.g., how admission and discharge basis are defined, how
    admission and discharge data are collected, how admission and
    discharge data are linked, and whether or not the State is able to
    collect such data.

**FORM T1-- EMPLOYMENT STATUS**

**TREATMENT PERFORMANCE MEASURE**

**PERCENTAGE POINT CHANGE IN EMPLOYMENT STATUS (From Admission to
Discharge)**

**STATE: REPORTING PERIOD: FROM\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(MM/DD/YYYY) (MM/DD/YYYY)

  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ---------- ------- ------------ -------
            **TOTAL**           **WHITE**           **BLACK**           **NATIVE             **ASIAN**           **AMERICAN           **MORE THAN          **UNKNOWN**           **NOT              **HISPANIC   
                                                                        HAWAIIAN/                                INDIA/               ONE RACE                                   HISPANIC           OR LATINO**  
                                                                        OTHER                                    ALASKA               REPORTED**                                 OR                              
                                                                        PACIFIC                                  NATIVE**                                                        LATINO**                        
                                                                        ISLANDER**                                                                                                                               

  **AGE**   **M**       **F**   **M**       **F**   **M**       **F**   **M**        **F**   **M**       **F**   **M**        **F**   **M**        **F**   **M**         **F**   **M**      **F**   **M**        **F**

  11 AND                                                                                                                                                                                                         
  UNDER                                                                                                                                                                                                          

  12-14                                                                                                                                                                                                          

  15-17                                                                                                                                                                                                          

  18-24                                                                                                                                                                                                          

  25-44                                                                                                                                                                                                          

  45-64                                                                                                                                                                                                          

  65 AND                                                                                                                                                                                                         
  OVER                                                                                                                                                                                                           

  TOTAL                                                                                                                                                                                                          
  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ---------- ------- ------------ -------

M= Male; F= Female

**The section below should be completed at the time data is entered in
the table above**

##### T1.1 [ٱ]{dir="rtl"} Client Self Report 

What is the source of data for [ٱ]{dir="rtl"} Administrative Data Source
[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

this table? (Select all that apply)

##### T1.2 **[ٱ]{dir="rtl"}** Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) [ٱ]{dir="rtl"} Admission is on the first
date of service in a Program/ Service Delivery Unit AND Discharge is on
the last date of service in a Program/ Service Delivery Unit

[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**T1.3** [ٱ]{dir="rtl"} Not Applicable, data reported on form is
collected at time period other than discharge **➜** Specify:
[ٱ]{dir="rtl"} In-Treatment data \_\_\_\_days post admission OR
[ٱ]{dir="rtl"} Follow-up data \_\_months

How was the discharge data [ٱ]{dir="rtl"} Discharge data is collected
for the census of all clients who were admitted to treatment post
[ٱ]{dir="rtl"} admission [ٱ]{dir="rtl"} discharge

collected? (Select one) [ٱ]{dir="rtl"} Discharge data is collected for a
sample of all clients who were admitted to treatment [ٱ]{dir="rtl"}
Other: Specify\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Discharge records are collected or created for all
clients who were admitted to treatment

[ٱ]{dir="rtl"} Discharge records are NOT completed for some clients who
were admitted to treatment. Specify proportion of clients without a
discharge record: \_\_\_\_\_\_\_\_\_\_%

##### T1.4 **[ٱ]{dir="rtl"}** Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID). Select type of UCID: **[ٱ]{dir="rtl"}** Statewide **[ٱ]{dir="rtl"}** County/Regional **[ٱ]{dir="rtl"}** Facility

Was the admission and [ٱ]{dir="rtl"} No, State Management Information
System does not utilize a UCID that allows comparison of admission and
discharge data on a client specific basis (data developed on a

discharge data linked? cohort basis) or State relied on other data
sources for post admission data

(Select one) [ٱ]{dir="rtl"} No, admission and discharge records were
matched using probabilistic record matching

T1.5 [ٱ]{dir="rtl"} Not Applicable, data reported above

Why are you Unable to Report? [ٱ]{dir="rtl"} Information is not
collected at Admission [ٱ]{dir="rtl"} Information is not collected at
Discharge [ٱ]{dir="rtl"} Information not collected by categories
requested

(Select all that apply) [ٱ]{dir="rtl"} State collects information on the
indicator area but utilizes a different measure [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Performance Measure Data Collection**

**Interim Standard -- Percentage Point Change in Employment Status**

  ------------------ ----------------------------------------------------
  GOAL               To improve the employment status of persons treated
                     in the State's substance abuse treatment system.

  MEASURE            The change in percentage of *all clients receiving
                     treatment* who reported being employed (including
                     part-time) at discharge.

  DEFINITIONS        Change in percentage of *all clients receiving
                     treatment* who reported being employed (including
                     part-time) at discharge equals the percentage of
                     clients reporting being employed (including
                     part-time) at admission subtracted from the
                     percentage of clients reporting being employed
                     (including part-time) at discharge.
  ------------------ ----------------------------------------------------

> **For example:**

  ----------------- ---------------- --------------- --------------------
  Category          Admission (%)    Discharge (%)   Difference (%)

  Employed          15               45              +30
  (including                                         
  part-time)                                         
  ----------------- ---------------- --------------- --------------------

> Thus there was a 30 percentage point increase in the number of clients
> reporting being employed (including part-time) at discharge.

+-----------------+----------------------------------------------------+
| HEALTHY PEOPLE\ | Related to Objective 26-8 (Developmental): Reduce  |
| 2010 OBJECTIVES | the cost of lost productivity in the workplace due |
|                 | to alcohol and drug use.                           |
+-----------------+----------------------------------------------------+
| INTERIM         | Data related to employment status should be        |
| STANDARD FOR    | collected using the relevant Treatment Episode     |
| DATA COLLECTION | Data Set (TEDS) element at admission and           |
|                 | discharge. States would report percentage          |
|                 | differences in employment status for the 30 days   |
|                 | preceding admission to treatment, and the 30 days  |
|                 | preceding discharge (or since admission if less    |
|                 | than 30 days). States should track client-level    |
|                 | data by matching admission to discharge records    |
|                 | through a unique statewide client ID.              |
|                 |                                                    |
|                 | "Employed" includes those employed full time (35   |
|                 | or more hours per week) and part time (less than   |
|                 | 35 hours per week). **Exclude those not in the     |
|                 | labor force, including, homemakers, students,      |
|                 | those disabled, retired persons, those not looking |
|                 | for work in the last 30 days and those in          |
|                 | institutions.**                                    |
+-----------------+----------------------------------------------------+
| DATA SOURCE(S)  | Primary data collection based on State standard    |
|                 | for admission and discharge client data (e.g.,     |
|                 | TEDS, Addiction Severity Index (ASI), ASI-Lite,    |
|                 | etc.).                                             |
+-----------------+----------------------------------------------------+
| DATA ISSUES     | State instruments may differ from TEDS             |
|                 | definitions. States may lack a unique statewide    |
|                 | client ID to link admission and discharge records. |
+-----------------+----------------------------------------------------+
| FORM            | T1                                                 |
+-----------------+----------------------------------------------------+

**State Description of Employment Status Data Collection (Form T1)**

+-------------------+--------------------------------------------------+
| GOAL              | To improve the employment status of persons      |
|                   | treated in the States substance abuse treatment  |
|                   | systems.                                         |
+-------------------+--------------------------------------------------+
| MEASURE           | The change in percentage of *all clients         |
|                   | receiving treatment* who reported being employed |
|                   | (including part-time) at discharge               |
+-------------------+--------------------------------------------------+
| STATE CONFORMANCE | States should detail exactly how this            |
| TO INTERIM        | information is collected. Where data and methods |
| STANDARD          | vary from interim standard, variance should be   |
|                   | described.                                       |
+-------------------+--------------------------------------------------+
|                   | State collects admission and discharge data on   |
|                   | employment that can be reported using TEDS       |
|                   | definitions.                                     |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using data other than        |
|                   | admission and discharge data.                    |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using administrative data.   |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
| DATA SOURCE(S)    | Source(s):                                       |
+-------------------+--------------------------------------------------+
| DATA ISSUES       | Issues:                                          |
+-------------------+--------------------------------------------------+
| DATA PLANS IF     | State should provide time-framed plans for       |
| DATA IS NOT       | capturing employment status data on all clients, |
| AVAILABLE         | if data is not currently available. Plans should |
|                   | also discuss barriers, resource needs and        |
|                   | estimates of cost.                               |
+-------------------+--------------------------------------------------+

FORM T2--LIVING STATUS

TREATMENT PERFORMANCE MEASURE

**PERCENTAGE POINT CHANGE IN HOMELESSNESS^\*^ (From Admission to
Discharge)**

**STATE: REPORTING PERIOD: FROM\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(MM/DD/YYYY) (MM/DD/YYYY)

  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ------- ---------- ------- ------- ------------ ------- ------- --
            **TOTAL**           **WHITE**           **BLACK**           **NATIVE             **ASIAN**           **AMERICAN           **MORE THAN          **UNKNOWN**                   **NOT                      **HISPANIC                   
                                                                        HAWAIIAN/                                INDIA/               ONE RACE                                           HISPANIC                   OR LATINO**                  
                                                                        OTHER                                    ALASKA               REPORTED**                                         OR                                                      
                                                                        PACIFIC                                  NATIVE**                                                                LATINO**                                                
                                                                        ISLANDER**                                                                                                                                                               

  **AGE**   **M**       **F**   **M**       **F**   **M**       **F**   **M**        **F**   **M**       **F**   **M**        **F**   **M**        **F**                 **M**   **F**              **M**   **F**                **M**   **F**   

  11 AND                                                                                                                                                                                                                                         
  UNDER                                                                                                                                                                                                                                          

  12-14                                                                                                                                                                                                                                          

  15-17                                                                                                                                                                                                                                          

  18-24                                                                                                                                                                                                                                          

  25-44                                                                                                                                                                                                                                          

  45-64                                                                                                                                                                                                                                          

  65 AND                                                                                                                                                                                                                                         
  OVER                                                                                                                                                                                                                                           

  TOTAL                                                                                                                                                                                                                                          
  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ------- ---------- ------- ------- ------------ ------- ------- --

M= Male; F= Female \* See detail sheet for definition of homelessness
(or at risk of being homeless)

#### The section below should be completed at the time data is entered in the table above

##### T2.1 [ٱ]{dir="rtl"} Client Self Report 

What is the source of data for [ٱ]{dir="rtl"} Administrative Data Source
[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

this table? (Select all that apply)

##### T2.2 **[ٱ]{dir="rtl"}** Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) [ٱ]{dir="rtl"} Admission is on the first
date of service in a Program/ Service Delivery Unit AND Discharge is on
the last date of service in a Program/ Service Delivery Unit

[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**T2.3** [ٱ]{dir="rtl"} Not Applicable, data reported on form is
collected at time period other than discharge **➜** Specify:
[ٱ]{dir="rtl"} In-Treatment data \_\_\_\_days post admission OR
[ٱ]{dir="rtl"} Follow-up data \_\_\_\_months

How was the discharge data [ٱ]{dir="rtl"} Discharge data is collected
for the census of all clients who were admitted to treatment post
[ٱ]{dir="rtl"} admission [ٱ]{dir="rtl"} discharge

collected? (Select one) [ٱ]{dir="rtl"} Discharge data is collected for a
sample of all clients who were admitted to treatment [ٱ]{dir="rtl"}
Other: Specify\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Discharge records are collected or created for all
clients who were admitted to treatment

[ٱ]{dir="rtl"} Discharge records are NOT completed for some clients who
were admitted to treatment. Specify proportion of clients without a
discharge record: \_\_\_\_\_\_\_\_\_\_%

##### T2.4 **[ٱ]{dir="rtl"}** Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID). Select type of UCID: **[ٱ]{dir="rtl"}** Statewide **[ٱ]{dir="rtl"}** County/Regional **[ٱ]{dir="rtl"}** Facility

Was the admission and [ٱ]{dir="rtl"} No, State Management Information
System does not utilize a UCID that allows comparison of admission and
discharge data on a client specific basis (data developed on a

discharge data linked? cohort basis) or State relied on other data
sources for post admission data

(Select one) [ٱ]{dir="rtl"} No, admission and discharge records were
matched using probabilistic record matching

T2.5 [ٱ]{dir="rtl"} Not Applicable, data reported above

Why are you Unable to Report? [ٱ]{dir="rtl"} Information is not
collected at Admission [ٱ]{dir="rtl"} Information is not collected at
Discharge [ٱ]{dir="rtl"} Information not collected by categories
requested

(Select all that apply) [ٱ]{dir="rtl"} State collects information on the
indicator area but utilizes a different measure [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Performance Measure Data Collection**

**Interim Standard -- Percentage Point Change in Homelessness (Living
Status)**

  ------------------ ----------------------------------------------------
  GOAL               To improve living conditions of persons treated in
                     the State's substance abuse treatment system.

  MEASURE            The change in percentage of *all clients receiving
                     treatment* who reported being homeless at discharge.

  DEFINITIONS        Change in percentage of *all clients receiving
                     treatment* who reported being homeless at discharge
                     equals the percentage of clients reporting being
                     homeless at admission subtracted from the percentage
                     of clients reporting being homeless at discharge.
  ------------------ ----------------------------------------------------

> **For example:**

  -------------- ----------------- ----------------- ----------------------
  Category       Admission (%)     Discharge (%)     Difference (%)

  Homeless       10                8                 -2
  -------------- ----------------- ----------------- ----------------------

> Thus there was a 2 percentage point decrease in the number of clients
> reporting being homeless at discharge.

+------------------+---------------------------------------------------+
| HEALTHY PEOPLE   | No Related Objectives                             |
| 2010 OBJECTIVES  |                                                   |
+------------------+---------------------------------------------------+
| INTERIM STANDARD | Data related to living status should be collected |
| FOR DATA         | using the relevant Treatment Episode Data Set     |
| COLLECTION       | (TEDS) element at admission and discharge. The    |
|                  | reported measure will reflect differences in      |
|                  | homelessness at admission to treatment, and at    |
|                  | discharge. States should track client-level data  |
|                  | by matching admission to discharge records        |
|                  | through a unique statewide client ID.             |
|                  |                                                   |
|                  | TEDS defines homeless as clients with no fixed    |
|                  | address; includes shelters. Dependent living (at  |
|                  | risk for being homeless) is defined as clients    |
|                  | living in a supervised setting such as a          |
|                  | residential institution, halfway house or group   |
|                  | home.                                             |
+------------------+---------------------------------------------------+
| DATA SOURCE(S)   | Primary data collection based on State standard   |
|                  | for admission and discharge client data (e.g.,    |
|                  | TEDS, Addiction Severity Index (ASI), ASI-Lite,   |
|                  | etc.).                                            |
+------------------+---------------------------------------------------+
| DATA ISSUES      | State instruments may differ from TEDS            |
|                  | definitions. States may lack a unique statewide   |
|                  | client ID to link admission and discharge         |
|                  | records.                                          |
+------------------+---------------------------------------------------+
| FORM             | T2                                                |
+------------------+---------------------------------------------------+

**State Description of Homelessness (Living Status) Data Collection
(Form T2)**

+-------------------+--------------------------------------------------+
| GOAL              | To improve living conditions of persons treated  |
|                   | in the State's substance abuse treatment system. |
+-------------------+--------------------------------------------------+
| MEASURE           | The change in percentage of *all clients         |
|                   | receiving treatment* who reported being homeless |
|                   | at discharge.                                    |
+-------------------+--------------------------------------------------+
| STATE CONFORMANCE | States should detail exactly how this            |
| TO INTERIM        | information is collected. Where data and methods |
| STANDARD          | vary from interim standard, variance should be   |
|                   | described.                                       |
+-------------------+--------------------------------------------------+
|                   | State collects admission and discharge data on   |
|                   | living status that can be reported using TEDS    |
|                   | definitions.                                     |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using data other than        |
|                   | admission and discharge data.                    |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using administrative data.   |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
| DATA SOURCE(S)    | Source(s):                                       |
+-------------------+--------------------------------------------------+
| DATA ISSUES       | Issues:                                          |
+-------------------+--------------------------------------------------+
| DATA PLANS IF     | State should provide time-framed plans for       |
| DATA IS NOT       | capturing living status data on all clients, if  |
| AVAILABLE         | data is not currently available. Plans should    |
|                   | also discuss barriers, resource needs and        |
|                   | estimates of cost.                               |
+-------------------+--------------------------------------------------+

FORM T3--CRIMINAL JUSTICE INVOLVEMENT

TREATMENT PERFORMANCE MEASURE

**PERCENTAGE POINT CHANGE IN PERSONS ARRESTED (From Admission to
Discharge)**

**STATE: REPORTING PERIOD: FROM\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(MM/DD/YYYY) MM/DD/YYYY)

  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ---------- ------- ------------ -------
            **TOTAL**           **WHITE**           **BLACK**           **NATIVE             **ASIAN**           **AMERICAN           **MORE THAN          **UNKNOWN**           **NOT              **HISPANIC   
                                                                        HAWAIIAN/                                INDIA/               ONE RACE                                   HISPANIC           OR LATINO**  
                                                                        OTHER                                    ALASKA               REPORTED**                                 OR                              
                                                                        PACIFIC                                  NATIVE**                                                        LATINO**                        
                                                                        ISLANDER**                                                                                                                               

  **AGE**   **M**       **F**   **M**       **F**   **M**       **F**   **M**        **F**   **M**       **F**   **M**        **F**   **M**        **F**   **M**         **F**   **M**      **F**   **M**        **F**

  11 AND                                                                                                                                                                                                         
  UNDER                                                                                                                                                                                                          

  12-14                                                                                                                                                                                                          

  15-17                                                                                                                                                                                                          

  18-24                                                                                                                                                                                                          

  25-44                                                                                                                                                                                                          

  45-64                                                                                                                                                                                                          

  65 AND                                                                                                                                                                                                         
  OVER                                                                                                                                                                                                           

  TOTAL                                                                                                                                                                                                          
  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ---------- ------- ------------ -------

M= Male; F= Female

**The section below should be completed at the time data is entered in
the table above**

##### T3.1 [ٱ]{dir="rtl"} Client Self Report 

What is the source of data for [ٱ]{dir="rtl"} Administrative Data Source
[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

this table? (Select all that apply)

##### T3.2 [ٱ]{dir="rtl"} Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service how is 

#####  Admission/Discharge has been received for 30 days

Basis defined? (Select one) [ٱ]{dir="rtl"} Admission is on the first
date of service in a Program/ Service Delivery Unit AND Discharge is on
the last date of service in a Program/ Service Delivery Unit

[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**T3.3** [ٱ]{dir="rtl"} Not Applicable, data reported on form is
collected at time period other than discharge **➜** Specify:
[ٱ]{dir="rtl"} In-Treatment data \_\_\_\_days post admission OR
[ٱ]{dir="rtl"} Follow-up data \_\_\_\_months

How was the discharge data [ٱ]{dir="rtl"} Discharge data is collected
for the census of all clients who were admitted to treatment post
[ٱ]{dir="rtl"} admission [ٱ]{dir="rtl"} discharge

collected? (Select one) [ٱ]{dir="rtl"} Discharge data is collected for a
sample of all clients who were admitted to treatment [ٱ]{dir="rtl"}
Other: Specify\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Discharge records are collected or created for all
clients who were admitted to treatment

[ٱ]{dir="rtl"} Discharge records are NOT completed for some clients who
were admitted to treatment. Specify proportion of clients without a
discharge record: \_\_\_\_\_\_\_\_\_\_%

##### T3.4 **[ٱ]{dir="rtl"}** Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID). Select type of UCID: **[ٱ]{dir="rtl"}** Statewide **[ٱ]{dir="rtl"}** County/Regional **[ٱ]{dir="rtl"}** Facility

Was the admission and [ٱ]{dir="rtl"} No, State Management Information
System does not utilize a UCID that allows comparison of admission and
discharge data on a client specific basis (data developed on a

discharge data linked? cohort basis) or State relied on other data
sources for post admission data

(Select one) [ٱ]{dir="rtl"} No, admission and discharge records were
matched using probabilistic record matching

T3.5 [ٱ]{dir="rtl"} Not Applicable, data reported above

Why are you Unable to Report? [ٱ]{dir="rtl"} Information is not
collected at Admission [ٱ]{dir="rtl"} Information is not collected at
Discharge [ٱ]{dir="rtl"} Information not collected by categories
requested

(Select all that apply) [ٱ]{dir="rtl"} State collects information on the
indicator area but utilizes a different measure [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Performance Measure Data Collection**

## Interim Standard --Percentage Point Change of Persons Arrested

  ------------------ ----------------------------------------------------
  GOAL               To reduce the criminal justice involvement of
                     persons treated in the State's substance abuse
                     treatment system.

  MEASURE            The change in percentage of persons arrested in the
                     last 30 days at discharge for *all clients receiving
                     treatment*.

  DEFINITIONS        Change in percentage of persons arrested in the last
                     30 days at discharge for *all clients receiving
                     treatment* equals the percentage of clients who were
                     arrested in the 30 days prior to admission
                     subtracted from the percentage of clients who were
                     arrested in the last 30 days at discharge. An arrest
                     is any arrest.
  ------------------ ----------------------------------------------------

> **For example:**

  --------------- ----------------- ---------------- ---------------------
  Category        Admission (%)     Discharge (%)    Difference (%)

  Arrested        35                15               -20
  --------------- ----------------- ---------------- ---------------------

> Thus there was a 20 percentage point decrease in the number of clients
> arrested in the last 30 days at discharge.

+------------------+---------------------------------------------------+
| HEALTHY PEOPLE\  | Related to Objective 26-8 (Developmental): Reduce |
| 2010 OBJECTIVES  | the cost of lost productivity in the workplace    |
|                  | due to alcohol and drug use. For drug abuse, most |
|                  | (56 percent) of the estimated productivity losses |
|                  | were associated with crime, including             |
|                  | incarcerated perpetrators (26 percent) of         |
|                  | drug-related crime.                               |
+------------------+---------------------------------------------------+
| INTERIM STANDARD | States will collect information on the percentage |
| FOR DATA         | of clients with at least one arrest (a            |
| COLLECTION       | dichotomous response item: arrested -- yes/no) in |
|                  | the 30 days preceding admission to treatment and  |
|                  | the percentage of clients with at least one       |
|                  | arrest in the 30 days prior at discharge (or      |
|                  | since admission if less than 30 days). States     |
|                  | should track client-level data by matching        |
|                  | admission to discharge records through a unique   |
|                  | statewide client ID.                              |
|                  |                                                   |
|                  | A client who has one or more arrest counts (not   |
|                  | charges) in the past 30 days, is included in this |
|                  | measure.                                          |
+------------------+---------------------------------------------------+
| DATA SOURCE(S)   | Primary data collection based on State standard   |
|                  | for admission and discharge client data. (e.g.,   |
|                  | TEDS, Addiction Severity Index (ASI), ASI-Lite,   |
|                  | etc.)                                             |
+------------------+---------------------------------------------------+
| DATA ISSUES      | State instruments may differ from TEDS            |
|                  | definitions. States may lack a unique statewide   |
|                  | client ID to link admission and discharge         |
|                  | records.                                          |
+------------------+---------------------------------------------------+
| FORM             | T3                                                |
+------------------+---------------------------------------------------+

State Description of Number of Arrests Data Collection (Form T3)

+------------------+---------------------------------------------------+
| GOAL             | To reduce the criminal justice involvement of     |
|                  | persons treated in the State's substance abuse    |
|                  | treatment system.                                 |
+------------------+---------------------------------------------------+
| MEASURE          | The change in percentage of persons arrested in   |
|                  | the last 30 days at discharge for *all clients    |
|                  | receiving treatment*.                             |
+------------------+---------------------------------------------------+
| STATE            | States should detail exactly how this information |
| CONFORMANCE TO   | is collected. Where data and methods vary from    |
| INTERIM STANDARD | interim standard, variance should be described.   |
+------------------+---------------------------------------------------+
|                  | State collects admission and discharge data on    |
|                  | criminal justice involvement that can be reported |
|                  | as a Yes/No response.                             |
|                  |                                                   |
|                  | YES\_\_\_\_\_\_\_\_\_\_\_\_                       |
|                  | NO\_\_\_\_\_\_\_\_\_\_                            |
+------------------+---------------------------------------------------+
|                  | State reported data using data other than         |
|                  | admission and discharge data.                     |
|                  |                                                   |
|                  | YES\_\_\_\_\_\_\_\_\_\_\_\_                       |
|                  | NO\_\_\_\_\_\_\_\_\_\_                            |
+------------------+---------------------------------------------------+
|                  | State reported data using administrative data.    |
|                  |                                                   |
|                  | YES\_\_\_\_\_\_\_\_\_\_\_\_                       |
|                  | NO\_\_\_\_\_\_\_\_\_\_                            |
+------------------+---------------------------------------------------+
| DATA SOURCE(S)   | Source(s):                                        |
+------------------+---------------------------------------------------+
| DATA ISSUES      | Issues:                                           |
|                  |                                                   |
|                  | States will need to discuss if information on all |
|                  | arrests is not available.                         |
+------------------+---------------------------------------------------+
| DATA PLANS IF    | State should provide time-framed plans for        |
| DATA IS NOT      | capturing arrest data on all clients, if data is  |
| AVAILABLE        | not currently available. Plans should also        |
|                  | discuss barriers, resource needs and estimates of |
|                  | cost.                                             |
+------------------+---------------------------------------------------+

FORM T4-- ALCOHOL USE

TREATMENT PERFORMANCE MEASURE

**PERCENTAGE POINT CHANGE IN ABSTINENCE (From Admission to Discharge)**

######### STATE: REPORTING PERIOD: FROM\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ TO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(MM/DD/YYYY) (MM/DD/YYYY)

  --------- ----------- ------- ----------- ------- ----------- ------- ------- ------------ ------- ------- ----------- ------- ------- ------------ ------- ------- ------------ ------- ------- ------------- ------- ---------- ------- ------- ------------ ------- -------
            **TOTAL**           **WHITE**           **BLACK**                   **NATIVE                     **ASIAN**                   **AMERICAN                   **MORE THAN                  **UNKNOWN**           **NOT                      **HISPANIC           
                                                                                HAWAIIAN/                                                INDIA/                       ONE RACE                                           HISPANIC                   OR LATINO**          
                                                                                OTHER                                                    ALASKA                       REPORTED**                                         OR                                              
                                                                                PACIFIC                                                  NATIVE**                                                                        LATINO**                                        
                                                                                ISLANDER**                                                                                                                                                                               

  **AGE**   **M**       **F**   **M**       **F**   **M**       **F**   **M**                **F**   **M**               **F**   **M**                **F**   **M**                **F**   **M**                 **F**              **M**   **F**                **M**   **F**

  11 AND                                                                                                                                                                                                                                                                 
  UNDER                                                                                                                                                                                                                                                                  

  12-14                                                                                                                                                                                                                                                                  

  15-17                                                                                                                                                                                                                                                                  

  18-24                                                                                                                                                                                                                                                                  

  25-44                                                                                                                                                                                                                                                                  

  45-64                                                                                                                                                                                                                                                                  

  65 AND                                                                                                                                                                                                                                                                 
  OVER                                                                                                                                                                                                                                                                   

  TOTAL                                                                                                                                                                                                                                                                  
  --------- ----------- ------- ----------- ------- ----------- ------- ------- ------------ ------- ------- ----------- ------- ------- ------------ ------- ------- ------------ ------- ------- ------------- ------- ---------- ------- ------- ------------ ------- -------

M= Male; F= Female

**The section below should be completed at the time data is entered in
the table above**

##### T4.1 [ٱ]{dir="rtl"} Client Self Report **[ٱ]{dir="rtl"}** Client Self Report confirmed by another source. ➜ If checked, select one confirmation source: **[ٱ]{dir="rtl"}** Urinalysis, blood test or other biological assay

What is the source of data for [ٱ]{dir="rtl"} Administrative Data Source
[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[ٱ]{dir="rtl"} Collateral source

this table? (Select all that apply) [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##### T4.2 **[ٱ]{dir="rtl"}** Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) [ٱ]{dir="rtl"} Admission is on the first
date of service in a Program/ Service Delivery Unit AND Discharge is on
the last date of service in a Program/ Service Delivery Unit

[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**T4.3** [ٱ]{dir="rtl"} Not Applicable, data reported on form is
collected at time period other than discharge **➜** Specify:
[ٱ]{dir="rtl"} In-Treatment data \_\_\_\_days post admission OR
[ٱ]{dir="rtl"} Follow-up data \_\_\_\_months

How was the discharge data [ٱ]{dir="rtl"} Discharge data is collected
for the census of all clients who were admitted to treatment post
[ٱ]{dir="rtl"} admission [ٱ]{dir="rtl"} discharge

collected? (Select one) [ٱ]{dir="rtl"} Discharge data is collected for a
sample of all clients who were admitted to treatment [ٱ]{dir="rtl"}
Other: Specify\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Discharge records are collected or created for all
clients who were admitted to treatment

[ٱ]{dir="rtl"} Discharge records are NOT completed for some clients who
were admitted to treatment. Specify proportion of clients without a
discharge record: \_\_\_\_\_\_\_\_\_\_%

##### T4.4 **[ٱ]{dir="rtl"}** Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID). Select type of UCID: **[ٱ]{dir="rtl"}** Statewide **[ٱ]{dir="rtl"}** County/Regional **[ٱ]{dir="rtl"}** Facility

Was the admission and [ٱ]{dir="rtl"} No, State Management Information
System does not utilize a UCID that allows comparison of admission and
discharge data on a client specific basis (data developed on a

discharge data linked? cohort basis) or State relied on other data
sources for post admission data

(Select one) [ٱ]{dir="rtl"} No, admission and discharge records were
matched using probabilistic record matching

T4.5 [ٱ]{dir="rtl"} Not Applicable, data reported above

Why are you Unable to Report? [ٱ]{dir="rtl"} Information is not
collected at Admission [ٱ]{dir="rtl"} Information is not collected at
Discharge [ٱ]{dir="rtl"} Information not collected by categories
requested

(Select all that apply) [ٱ]{dir="rtl"} State collects information on the
indicator area but utilizes a different measure [ٱ]{dir="rtl"} Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Performance Measure Data Collection**

**Interim Standard -- Percentage Point Change in Abstinence - Alcohol
Use**

  ------------------ ----------------------------------------------------
  GOAL               To reduce substance abuse to protect the health,
                     safety, and quality of life for all.

  MEASURE            The change in percentage of *all clients receiving
                     treatment* who reported abstinence at discharge.

  DEFINITIONS        Change in percentage of *all clients receiving
                     treatment* who reported abstinence at discharge
                     equals the percentage of clients reporting
                     abstinence at admission subtracted from the
                     percentage of clients reporting abstinence at
                     discharge.
  ------------------ ----------------------------------------------------

> **For example**:

  ----------------- ---------------- ---------------- --------------------
  Category          Admission (%)    Discharge (%)    Difference (%)

  No past month use 10               50               +40
  (abstinence)                                        
  ----------------- ---------------- ---------------- --------------------

> Thus there was a 40 percentage point increase in the number of clients
> reporting abstinence at discharge.

+------------------+---------------------------------------------------+
| HEALTHY PEOPLE\  | Related to: Objective 26-9: Increase the age and  |
| 2010 OBJECTIVES  | proportion of adolescents who remain alcohol and  |
|                  | drug free; Objective 26-10: Reduce past month use |
|                  | of illicit substances; Objective 26-11: Reduce    |
|                  | the proportion of persons engaging in binge       |
|                  | drinking of alcoholic beverages; and Objective    |
|                  | 26-12: Reduce average annual alcohol consumption. |
+------------------+---------------------------------------------------+
| INTERIM STANDARD | Data related to alcohol use should be collected   |
| FOR DATA         | using the relevant Treatment Episode Data Set     |
| COLLECTION       | (TEDS) elements at admission and discharge to     |
|                  | identify primary, secondary, and tertiary alcohol |
|                  | use and the associated frequency of use data. The |
|                  | reported measure will reflect differences in      |
|                  | abstinence in the 30 days preceding admission to  |
|                  | AOD treatment, and in the 30 days prior to        |
|                  | discharge (or since admission if less than 30     |
|                  | days). States should track client-level data by   |
|                  | matching admission to discharge records through a |
|                  | unique statewide client ID.                       |
|                  |                                                   |
|                  | Abstinence from alcohol use is defined as no past |
|                  | month use of alcohol.                             |
+------------------+---------------------------------------------------+
| DATA SOURCE(S)   | Primary data collection based on State standard   |
|                  | for admission and discharge client data. (e.g.,   |
|                  | TEDS, Addiction Severity Index (ASI), ASI-Lite,   |
|                  | etc.)                                             |
+------------------+---------------------------------------------------+
| DATA ISSUES      | State instruments may differ from TEDS            |
|                  | definitions. States may lack a unique statewide   |
|                  | client ID to link admission and discharge         |
|                  | records.                                          |
+------------------+---------------------------------------------------+
| FORM             | T4                                                |
+------------------+---------------------------------------------------+

**State Description of Alcohol Use Data Collection (Form T4)**

+-------------------+--------------------------------------------------+
| GOAL              | To reduce substance abuse to protect the health, |
|                   | safety, and quality of life for all.             |
+-------------------+--------------------------------------------------+
| MEASURE           | The change in percentage of *all clients         |
|                   | receiving treatment* who reported abstinence at  |
|                   | discharge.                                       |
+-------------------+--------------------------------------------------+
| STATE CONFORMANCE | State should detail exactly how this information |
| TO INTERIM        | is collected. Where data and methods vary from   |
| STANDARD          | interim standard, variance should be described.  |
+-------------------+--------------------------------------------------+
|                   | State collects admission and discharge data on   |
|                   | alcohol use that can be reported using TEDS      |
|                   | definitions.                                     |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using data other than        |
|                   | admission and discharge data.                    |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using administrative data.   |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
| DATA SOURCE(S)    | Source(s):                                       |
+-------------------+--------------------------------------------------+
| DATA ISSUES       | Issues:                                          |
+-------------------+--------------------------------------------------+
| DATA PLANS IF     | State should provide time-framed plans for       |
| DATA IS NOT       | capturing alcohol use data on all clients, if    |
| AVAILABLE         | data is not currently available. Plans should    |
|                   | also discuss barriers, resource needs and        |
|                   | estimates of cost.                               |
+-------------------+--------------------------------------------------+

FORM T5-- OTHER DRUG USE

TREATMENT PERFORMANCE MEASURE

**PERCENTAGE POINT CHANGE IN ABSTINENCE (From Admission to Discharge)**

**STATE: REPORTING PERIOD: FROM\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(MM/DD/YYYY) (MM/DD/YYYY)

  --------- ----------- ------- ----------- ------- ------- ----------- ------- ------- ------------ ------- ------- ----------- ------- ------- ------------ ------- ------- ------------ ------- ------- ------------- ------- ------- ---------- ------- ------- ------------ ------- ------- --
            **TOTAL**           **WHITE**                   **BLACK**                   **NATIVE                     **ASIAN**                   **AMERICAN                   **MORE THAN                  **UNKNOWN**                   **NOT                      **HISPANIC                   
                                                                                        HAWAIIAN/                                                INDIA/                       ONE RACE                                                   HISPANIC                   OR LATINO**                  
                                                                                        OTHER                                                    ALASKA                       REPORTED**                                                 OR                                                      
                                                                                        PACIFIC                                                  NATIVE**                                                                                LATINO**                                                
                                                                                        ISLANDER**                                                                                                                                                                                               

  **AGE**   **M**       **F**               **M**   **F**               **M**   **F**                **M**   **F**               **M**   **F**                **M**   **F**                **M**   **F**                 **M**   **F**              **M**   **F**                **M**   **F**   

  11 AND                                                                                                                                                                                                                                                                                         
  UNDER                                                                                                                                                                                                                                                                                          

  12-14                                                                                                                                                                                                                                                                                          

  15-17                                                                                                                                                                                                                                                                                          

  18-24                                                                                                                                                                                                                                                                                          

  25-44                                                                                                                                                                                                                                                                                          

  45-64                                                                                                                                                                                                                                                                                          

  65 AND                                                                                                                                                                                                                                                                                         
  OVER                                                                                                                                                                                                                                                                                           

  TOTAL                                                                                                                                                                                                                                                                                          
  --------- ----------- ------- ----------- ------- ------- ----------- ------- ------- ------------ ------- ------- ----------- ------- ------- ------------ ------- ------- ------------ ------- ------- ------------- ------- ------- ---------- ------- ------- ------------ ------- ------- --

M= Male; F= Female

**The section below should be completed at the time data is entered in
the table above**

##### T5.1 [ٱ]{dir="rtl"} Client Self Report **[ٱ]{dir="rtl"}** Client Self Report confirmed by another source. ➜ If checked, select one confirmation source: **[ٱ]{dir="rtl"}** Urinalysis, blood test or other biological assay

What is the source of data for [ٱ]{dir="rtl"} Administrative Data Source
[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[ٱ]{dir="rtl"} Collateral source

this table? (Select all that apply) [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##### T5.2 **[ٱ]{dir="rtl"}** Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) [ٱ]{dir="rtl"} Admission is on the first
date of service in a Program/ Service Delivery Unit AND Discharge is on
the last date of service in a Program/ Service Delivery Unit

[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**T5.3** [ٱ]{dir="rtl"} Not Applicable, data reported on form is
collected at time period other than discharge **➜** Specify:
[ٱ]{dir="rtl"} In-Treatment data \_\_\_\_days post admission OR
[ٱ]{dir="rtl"} Follow-up data \_\_\_\_months

How was the discharge data [ٱ]{dir="rtl"} Discharge data is collected
for the census of all clients who were admitted to treatment post
[ٱ]{dir="rtl"} admission [ٱ]{dir="rtl"} discharge

collected? (Select one) [ٱ]{dir="rtl"} Discharge data is collected for a
sample of all clients who were admitted to treatment [ٱ]{dir="rtl"}
Other: Specify\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Discharge records are collected or created for all
clients who were admitted to treatment

[ٱ]{dir="rtl"} Discharge records are NOT completed for some clients who
were admitted to treatment. Specify proportion of clients without a
discharge record: \_\_\_\_\_\_\_\_\_\_%

##### T5.4 **[ٱ]{dir="rtl"}** Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID). Select type of UCID: **[ٱ]{dir="rtl"}** Statewide **[ٱ]{dir="rtl"}** County/Regional **[ٱ]{dir="rtl"}** Facility

Was the admission and [ٱ]{dir="rtl"} No, State Management Information
System does not utilize a UCID that allows comparison of admission and
discharge data on a client specific basis (data developed on a

discharge data linked? cohort basis) or State relied on other data
sources for post admission data

(Select one) [ٱ]{dir="rtl"} No, admission and discharge records were
matched using probabilistic record matching

T5.5 [ٱ]{dir="rtl"} Not Applicable, data reported above

Why are you Unable to Report? [ٱ]{dir="rtl"} Information is not
collected at Admission [ٱ]{dir="rtl"} Information is not collected at
Discharge [ٱ]{dir="rtl"} Information not collected by categories
requested

(Select all that apply) [ٱ]{dir="rtl"} State collects information on the
indicator area but utilizes a different measure [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Performance Measure Data Collection

**Interim Standard -- Percentage Point Change in Abstinence -- Other
Drug Use**

  ------------------ ----------------------------------------------------
  GOAL               To reduce substance abuse to protect the health,
                     safety, and quality of life for all.

  MEASURE            The change in percentage of *all clients receiving
                     treatment* who reported abstinence at discharge.

  DEFINITIONS        Change in percentage of *all clients receiving
                     treatment* who reported abstinence at discharge
                     equals the percentage of clients reporting
                     abstinence at admission subtracted from the
                     percentage of clients reporting abstinence at
                     discharge.
  ------------------ ----------------------------------------------------

> **For example:**

  ----------------- ---------------- ---------------- ---------------------
  Category          Admission (%)    Discharge (%)    Difference (%)

  No past month use 30               50               +20
  (abstinence)                                        
  ----------------- ---------------- ---------------- ---------------------

> Thus there was a 20 percentage point increase in the number of clients
> reporting abstinence at discharge.

+-----------------+----------------------------------------------------+
| HEALTHY PEOPLE  | Related to Objective 26-10: Reduce past-month use  |
| 2010 OBJECTIVES | of illicit substances.                             |
+-----------------+----------------------------------------------------+
| INTERIM         | Treatment Episode Data Set (TEDS) elements at      |
| STANDARD FOR    | admission and discharge to identify primary,       |
| DATA COLLECTION | secondary, and tertiary other drug use and the     |
|                 | associated frequency of use data. The reported     |
|                 | measure will reflect differences in abstinence in  |
|                 | the 30 days preceding admission to AOD treatment,  |
|                 | and in the 30 days prior to discharge (or since    |
|                 | admission if less than 30 days). States should     |
|                 | track client-level data by matching admission to   |
|                 | discharge records through a unique statewide       |
|                 | client ID.                                         |
|                 |                                                    |
|                 | Abstinence from other drug use is defined as no    |
|                 | past month use of other drugs.                     |
+-----------------+----------------------------------------------------+
| DATA SOURCE(S   | Primary data collection based on State standard    |
|                 | for admission and discharge client data. (e.g.,    |
|                 | TEDS, Addiction Severity Index (ASI), ASI-Lite,    |
|                 | etc.)                                              |
+-----------------+----------------------------------------------------+
| DATA ISSUES     | State instruments may differ from TEDS             |
|                 | definitions. States may lack a unique statewide    |
|                 | client ID to link admission and discharge records. |
+-----------------+----------------------------------------------------+
| FORM            | T5                                                 |
+-----------------+----------------------------------------------------+

State Description of Other Drug Use Data Collection (Form T5)

+-------------------+--------------------------------------------------+
| GOAL              | To reduce substance abuse to protect the health, |
|                   | safety, and quality of life for all.             |
+-------------------+--------------------------------------------------+
| MEASURE           | The change in percentage of *all clients         |
|                   | receiving treatment* who reported abstinence at  |
|                   | discharge.                                       |
+-------------------+--------------------------------------------------+
| STATE CONFORMANCE | States should detail exactly how this            |
| TO INTERIM        | information is collected. Where data and methods |
| STANDARD          | vary from interim standard, variance should be   |
|                   | described.                                       |
+-------------------+--------------------------------------------------+
|                   | State collects admission and discharge data on   |
|                   | other drug use that can be reported using TEDS   |
|                   | definitions.                                     |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using data other than        |
|                   | admission and discharge data.                    |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
|                   | State reported data using administrative data.   |
|                   |                                                  |
|                   | YES\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                   | NO\_\_\_\_\_\_\_\_\_\_                           |
+-------------------+--------------------------------------------------+
| DATA SOURCE(S)    | Source(s):                                       |
+-------------------+--------------------------------------------------+
| DATA ISSUES       | Issues:                                          |
+-------------------+--------------------------------------------------+
| DATA PLANS IF     | State should provide time-framed plans for       |
| DATA IS           | capturing other drug use data on all clients, if |
| NOTAVAILABLE      | data is not currently available. Plans should    |
|                   | also discuss barriers, resource needs and        |
|                   | estimates of cost.                               |
+-------------------+--------------------------------------------------+

**[GENERAL INSTRUCTIONS FOR VOLUNTARY FORM T6]{.underline}:**

Number range CHAPTERInfectious Diseases Performance Measure

The goal of this form is to determine the degree to which the Single
State Agency provides and/or coordinates delivery of appropriate
infection control practices within its service system for substance
abuse treatment and prevention services. This form is a checklist to be
completed by the Single State Agency (SSA). For each item, please check
the box that best relates the degree to which that item describes the
State Infectious Disease control program/practices. The SSA should
develop a method for self-assessment to examine its policies, procedures
and services relevant to infectious disease control. The SSA should
attempt to use the same self-assessment criteria from year to year.

**Form T6**

**[CHARACTERISTICS DOCUMENTING APPROPRIATE PRACTICES IN INFECTIOUS
DISEASES CONTROL]{.underline}**

LEGEND: 0 - Not addressed; 1 - Inadequately addressed; 2 - Adequately
addressed; and

3 - Completely addressed (Select one for each response to questions 1-9)

1\. Single State Agency (SSA) maintains Memoranda of Understanding (MOU)
and/or other formal arrangements with appropriate public health agencies
and other social service providers to provide continuum of care for
persons with substance use disorders who are also at risk for infectious
diseases including screening, assessment, referral and treatment for
infectious diseases and preventive practices to control disease
transmission. Specify MOUs and other formal agreements maintained:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

0 1 2 3

G G G G

2\. Single State Agency (SSA) or other State agency certification,
licensure or contract provisions require infectious disease control
procedure/ policies (infectious disease control standards) at the
provider level.

Single State Agency or other State agency monitors provider
implementation of policies/

> procedures.
>
> Specify licensure; certification; or contract provision(s)
>
> Specify authority administering licensure; certification; or contract
> process\_\_\_\_\_\_\_\_\_\_\_\_
>
> Specify monitoring activity(ies)
>
> Specify proportion of programs meeting or exceeding infectious disease
> control standards during compliance monitoring
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_%

0 1 2 3

G G G G

CHARACTERISTICS OF HUMAN IMMUNODEFICIENCY VIRUS AND TUBERCULOSIS CONTROL
ACTIVITY

Is the State a "designated State" (i.e., cumulative case rate is equal
to or greater than 10/100,000)?

Yes No

Was the State a "designated State" (i.e., cumulative case rate is equal
to or greater than 10/100,000) in at least one of the last two years?

Yes No

If the State is a designated State, have HIV infection procedures been
developed by the principal agency for substance abuse in consultation
with the State Medical Director and in cooperation with the State
Department of Health/Communicable Disease Officer?

Yes No

Whether or not the State is a "designated State":

4\. Are early intervention services (EIS) projects provided at the site
where individuals are undergoing substance abuse treatment?

Specify the number of substance abuse treatment sites providing EIS:

> If the State funds more than one EIS project, specify number of such
> substance abuse treatment sites that are located in a rural area(s):

0 1 2 3

G G G G

5\. Do these sites have established linkages with a comprehensive
community resource network of related health and social service
organizations?

0 1 2 3

G G G G

6\. Do State funded substance abuse programs provide on-site or through
referral:

\(A\) Appropriate pre-test and post-test counseling for HIV and AIDS;

> \(B\) testing individuals with respect to such disease, including
> tests to diagnose the extent of the deficiency, tests to provide
> information on appropriate therapeutic measures, and for preventing
> and treating conditions arising from the disease; and
>
> \(C\) providing the therapeutic measures described in (B).

0 1 2 3

G G G G

7\. Are tuberculosis services as described in 42 U.S.C. 300x-24(a) and
45 C.F.R. 96.121 and 96.127, routinely made available, directly or
through arrangement with other public or nonprofit private entities, to
each individual receiving substance abuse treatment services?

0 1 2 3

G G G G

8\. Have infection control procedures as described in 45 C.F.R.
96.127(a)(3) been established by the principal agency of the State for
substance abuse, in cooperation with the State Medical Director and in
cooperation with the State Department of Health/Tuberculosis Control
Officer that which are designed to prevent the transmission of
tuberculosis?

> Specify the proportion of sites providing screening services directly
> or through
> referral:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Specify the proportion of sites providing case management activities
> as described in 45 C.F.R. 96.127(a)(4) of clients with TB to ensure
> that individuals receive necessary
> services:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

0 1 2 3

G G G G

9\. Have effective strategies been developed for monitoring programs
compliance with 45 C.F.R. 96.121 and 96.127? Specify the procedures
utilized:

Licensure or program certification standards

Yes No

Contract or grant specifications/requirements

Yes No

On-site monitoring

Yes No

Client records audits

Yes No

0 1 2 3

G G G G

Total \_\_\_\_\_ (Total the numbers in the boxes (possible 0-27) and
enter the number in the total cell.

FORM T7 -- SOCIAL SUPPORT OF RECOVERY

**PERCENTAGE POINT CHANGE IN INVOLVEMENT IN SOCIAL SUPPORT OF RECOVERY
(From Admission to Discharge)**

**STATE: REPORTING PERIOD: FROM\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(MM/DD/YYYY) (MM/DD/YYYY)

  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ---------- ------- ------------ -------
            **TOTAL**           **WHITE**           **BLACK**           **NATIVE             **ASIAN**           **AMERICAN           **MORE THAN          **UNKNOWN**           **NOT              **HISPANIC   
                                                                        HAWAIIAN/                                INDIA/               ONE RACE                                   HISPANIC           OR LATINO**  
                                                                        OTHER                                    ALASKA               REPORTED**                                 OR                              
                                                                        PACIFIC                                  NATIVE**                                                        LATINO**                        
                                                                        ISLANDER**                                                                                                                               

  **AGE**   **M**       **F**   **M**       **F**   **M**       **F**   **M**        **F**   **M**       **F**   **M**        **F**   **M**        **F**   **M**         **F**   **M**      **F**   **M**        **F**

  11 AND                                                                                                                                                                                                         
  UNDER                                                                                                                                                                                                          

  12-14                                                                                                                                                                                                          

  15-17                                                                                                                                                                                                          

  18-24                                                                                                                                                                                                          

  25-44                                                                                                                                                                                                          

  45-64                                                                                                                                                                                                          

  65 AND                                                                                                                                                                                                         
  OVER                                                                                                                                                                                                           

  TOTAL                                                                                                                                                                                                          
  --------- ----------- ------- ----------- ------- ----------- ------- ------------ ------- ----------- ------- ------------ ------- ------------ ------- ------------- ------- ---------- ------- ------------ -------

M= Male; F= Female

**The section below should be completed at the time data is entered in
the table above**

##### T7.1 [ٱ]{dir="rtl"} Client Self Report 

What is the source of data for [ٱ]{dir="rtl"} Administrative Data Source
[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##### T7.2 **[ٱ]{dir="rtl"}** Admission is on the first date of service, prior to which no service has been received for 30 days AND Discharge is on the last date of service, subsequent to which no service

How is Admission/ Discharge has been received for 30 days

Basis defined? (Select one) [ٱ]{dir="rtl"} Admission is on the first
date of service in a Program/ Service Delivery Unit AND Discharge is on
the last date of service in a Program/ Service Delivery Unit

[ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**T7.3** [ٱ]{dir="rtl"} Not Applicable, data reported on form is
collected at time period other than discharge **➜** Specify:
[ٱ]{dir="rtl"} In-Treatment data \_\_\_\_days post admission OR
[ٱ]{dir="rtl"} Follow-up data \_\_\_\_months

How was the discharge data [ٱ]{dir="rtl"} Discharge data is collected
for the census of all clients who were admitted to treatment post
[ٱ]{dir="rtl"} admission [ٱ]{dir="rtl"} discharge

collected? (Select one) [ٱ]{dir="rtl"} Discharge data is collected for a
sample of all clients who were admitted to treatment [ٱ]{dir="rtl"}
Other: Specify\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Discharge records are collected or created for all
clients who were admitted to treatment

[ٱ]{dir="rtl"} Discharge records are NOT completed for some clients who
were admitted to treatment. Specify proportion of clients without a
discharge record: \_\_\_\_\_\_\_\_\_\_%

##### T7.4 **[ٱ]{dir="rtl"}** Yes, all clients at admission were linked with discharge data using a Unique Client ID (UCID). Select type of UCID: **[ٱ]{dir="rtl"}** Statewide **[ٱ]{dir="rtl"}** County/Regional **[ٱ]{dir="rtl"}** Facility

Was the admission and [ٱ]{dir="rtl"} No, State Management Information
System does not utilize a UCID that allows comparison of admission and
discharge data on a client specific basis (data developed on a

discharge data linked? cohort basis) or State relied on other data
sources for post admission data

(Select one) [ٱ]{dir="rtl"} No, admission and discharge records were
matched using probabilistic record matching

T7.5 [ٱ]{dir="rtl"} Not Applicable, data reported above

Why are you Unable to Report? [ٱ]{dir="rtl"} Information is not
collected at Admission [ٱ]{dir="rtl"} Information is not collected at
Discharge [ٱ]{dir="rtl"} Information not collected by categories
requested

(Select all that apply) [ٱ]{dir="rtl"} State collects information on the
indicator area but utilizes a different measure [ٱ]{dir="rtl"} Other:
Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Performance Measure Data Collection**

**Interim Standard -- Percentage Point Change in Social Support of
Recovery**

  ----------------- -----------------------------------------------------
  GOAL              To improve clients' participation in social support
                    of recovery activities to reduce substance abuse to
                    protect the health, safety, and quality of life for
                    all.

  MEASURE           The change in percentage of *all clients receiving
                    treatment* who reported participation in one or more
                    social and or recovery support activity at discharge.

  DEFINITIONS       Change in percentage of *all clients receiving
                    treatment* who reported participation in one or more
                    social and recovery support activities at discharge
                    equals the percentage of clients reporting
                    participation at admission subtracted from the
                    percentage of clients reporting participation at
                    discharge.
  ----------------- -----------------------------------------------------

> **For example**:

  --------------------- --------------- ---------------- -----------------
  Category              Admission (%)   Discharge (%)    Difference (%)

  Participation in      10              50               +40
  social and/or                                          
  recovery support                                       
  activities                                             
  --------------------- --------------- ---------------- -----------------

> Thus there was a 40 percentage point increase in the number of clients
> reporting participation in social support of recovery at discharge.

+-----------------+----------------------------------------------------+
| HEALTHY PEOPLE  | Related to: Objective 26-9: Increase the age and   |
| 2010 OBJECTIVES | proportion of adolescents who remain alcohol and   |
|                 | drug free; Objective 26-10: Reduce past month use  |
|                 | of illicit substances; Objective 26-11: Reduce the |
|                 | proportion of persons engaging in binge drinking   |
|                 | of alcoholic beverages; and Objective 26-12:       |
|                 | Reduce average annual alcohol consumption.         |
+-----------------+----------------------------------------------------+
| INTERIM         | Data should be collected using the elements as     |
| STANDARD FOR    | follows:                                           |
| DATA COLLECTION |                                                    |
|                 | Participation in social support of recovery        |
|                 | activities is defined as attending self-help group |
|                 | meetings, attending religious/faith affiliated     |
|                 | recovery or self help group meetings, attending    |
|                 | meetings of organizations other than the           |
|                 | organizations described above or interactions with |
|                 | family members and/or friends supportive of        |
|                 | recovery.                                          |
|                 |                                                    |
|                 | The reported measure will reflect differences in   |
|                 | participation in the 30 days preceding admission   |
|                 | to substance abuse treatment, and in the 30 days   |
|                 | prior to discharge (or since admission if less     |
|                 | than 30 days). States should track client-level    |
|                 | data by matching admission to discharge records    |
|                 | through a unique Statewide client ID.              |
+-----------------+----------------------------------------------------+
| DATA SOURCE(S)  | Primary data collection based on State standard    |
|                 | for admission and discharge client data (e.g.,     |
|                 | TEDS, Addiction Severity Index (ASI), ASI-Lite,    |
|                 | etc.).                                             |
+-----------------+----------------------------------------------------+
| DATA ISSUES     | State instruments may differ from TEDS             |
|                 | definitions. States may lack a unique statewide    |
|                 | client ID to link admission and discharge records. |
+-----------------+----------------------------------------------------+
| FORM            | T7                                                 |
+-----------------+----------------------------------------------------+

**State Description of Social Support of Recovery Data Collection (Form
T7)**

+-----------------+----------------------------------------------------+
| GOAL            | To improve clients' participation in social        |
|                 | support of recovery activities to reduce substance |
|                 | abuse to protect the health, safety, and quality   |
|                 | of life for all.                                   |
+-----------------+----------------------------------------------------+
| MEASURE         | The change in percentage of *all clients receiving |
|                 | treatment* who reported participation in one or    |
|                 | more social and or recovery support activity at    |
|                 | discharge.                                         |
+-----------------+----------------------------------------------------+
| STATE           | States should detail exactly how this information  |
| CONFORMANCE TO  | is collected. Where data and methods vary from     |
| INTERIM         | interim standard, variance should be described.    |
| STANDARD        |                                                    |
+-----------------+----------------------------------------------------+
|                 | State collects admission and discharge data on     |
|                 | social support of recovery that can be reported    |
|                 | using definitions provided as follows:             |
|                 |                                                    |
|                 | Participation in social support of recovery        |
|                 | activities are defined as attending self-help,     |
|                 | attending religious/faith affiliated recovery or   |
|                 | self help groups, attending meetings of            |
|                 | organizations other than the organizations         |
|                 | described above or interactions with family        |
|                 | members and/or friends supportive of recovery.     |
|                 |                                                    |
|                 | YES\_\_\_\_\_\_\_\_\_\_\_\_ NO\_\_\_\_\_\_\_\_\_\_ |
+-----------------+----------------------------------------------------+
|                 | State reported data using data other than          |
|                 | admission and discharge data.                      |
|                 |                                                    |
|                 | YES\_\_\_\_\_\_\_\_\_\_\_\_ NO\_\_\_\_\_\_\_\_\_\_ |
+-----------------+----------------------------------------------------+
|                 | State reported data using administrative data.     |
|                 |                                                    |
|                 | YES\_\_\_\_\_\_\_\_\_\_\_\_ NO\_\_\_\_\_\_\_\_\_\_ |
+-----------------+----------------------------------------------------+
| DATA SOURCE(S)  | Source(s):                                         |
+-----------------+----------------------------------------------------+
| DATA ISSUES     | Issues:                                            |
+-----------------+----------------------------------------------------+
| DATA PLANS IF   | State should provide time-framed plans for         |
| DATA IS NOT     | capturing social support of recovery data on all   |
| AVAILABLE       | clients, if data is not currently available. Plans |
|                 | should also discuss barriers, resource needs and   |
|                 | estimates of cost.                                 |
+-----------------+----------------------------------------------------+

**FORM T8: RETENTION**

**(Length of Stay (in Weeks), Average Number of Services per Client,
Proportion of Clients Completing Treatment)**

**STATE:**

<table style="width:100%;">
<colgroup>
<col style="width: 20%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 11%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="7"><h4
id="proportion-of-clients-by-length-of-stay">Proportion of Clients by
Length of Stay</h4></td>
<td rowspan="2"><strong>H: Average Number of Services per
Client</strong></td>
<td rowspan="2"><strong>I: Proportion of Clients Completing
Treatment</strong></td>
</tr>
<tr class="even">
<td></td>
<td><strong>A: Average Length of Stay</strong></td>
<td><p><strong>B: 1 - 2</strong></p>
<p><strong>Weeks</strong></p></td>
<td><p><strong>C: 3 - 10</strong></p>
<p><strong>Weeks</strong></p></td>
<td><strong>D: 11 - 20 Weeks</strong></td>
<td><p><strong>E: 21 - 30</strong></p>
<p><strong>Weeks</strong></p></td>
<td><p><strong>F: 31 - 40</strong></p>
<p><strong>Weeks</strong></p></td>
<td><p><strong>G: 40+</strong></p>
<p><strong>Weeks</strong></p></td>
</tr>
<tr class="odd">
<td colspan="10"><h1 id="level-of-care">LEVEL OF CARE</h1></td>
</tr>
<tr class="even">
<td><h2 id="more-than-one-level-of-care-received">More than one level of
CARE received</h2></td>
<td><h2 id="section"></h2></td>
<td><h2 id="section-1"></h2></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>DETOXIFICATION (24-HOUR CARE)</strong></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td>1. Hospital Inpatient</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2. Free-Standing Residential</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><h2 id="rehabilitation-residential">REHABILITATION/
RESIDENTIAL</h2></td>
<td colspan="8"><h2 id="section-2"></h2></td>
</tr>
<tr class="odd">
<td>3. Hospital Inpatient</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4. Short-term (up to 30 days)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5. Long-term (over 30 days)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><h2 id="rehabilitation-ambulatory">REHABILITATION/
AMBULATORY</h2></td>
<td colspan="8"><h2 id="section-3"></h2></td>
</tr>
<tr class="odd">
<td>Outpatient</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6. Methadone</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7. Non-Methadone</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>8. Intensive Outpatient</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>9. Detoxification</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**How to complete voluntary Form T8 -- Retention**

This form covers care the principal agency of the State purchased **in
the State expenditure period** designated on Form 1**.**

**Length of stay (LOS)** is described by the date of first individual or
group addiction counseling service to the date of last contact for each
level of care (date at which no additional services are received within
thirty days).

Use **column A** to report the average length of stay and **columns
B-G** to report proportional frequency distribution of clients by
periods of lengths of stay at each level of care. For clients served in
more than one level of care (episode based care), the State should
report such information if available.

If data is available, use **column H** to report the average number of
discrete services provided (e.g., group counseling episodes, individual
counseling episodes, etc.) for each of the respective levels of care
including clients served in more than one level of care.

Use **column I** to report the proportion of persons completing
treatment for each of the respective levels of care including clients
served in more than one level of care.

SECTION IV - B

VOLUNTARY PREVENTION PERFORMANCE MEASURES

INSTRUCTIONS

PURPOSE

PREVENTION PERFORMANCE MEASURES

Data requested on the following forms:

Number of people served by: age, gender, race/ethnicity (Form Prevention
P1)

Number of Services, by Service Types (Form Prevention P2 "Service
Counts")

Number and Percent of Evidence-Based Programs and Strategies (Form
Prevention P3

"Program Counts")

Perception of Risk/Harm (of Substance Use) (Form Prevention P4)

Attitudes about Substance Use (Form Prevention P5)

30 day Substance Use (Forms Prevention P6)

GENERAL INSTRUCTIONS

The following set of instructions and optional forms are available for
States to complete **on a voluntary basis**. It is understood that, at
the current time, not all States have the infrastructure in place that
supports the reporting of such data. By participating on a voluntary
basis, States can communicate their current capacity to report on the
proposed SAPT supported program performance measures and will thus help
inform future activities leading towards full implementation of the
Performance Partnership Grant Program.

In completing these voluntary forms, please be sure to:

1\. Include all participants who participated in services from
prevention programs that received some or all of their funding from the
Substance Abuse Prevention and Treatment Block Grant. Recurring services
are defined in Minimum Data Set (MDS) descriptions as "\...efforts
undertaken with the same group of people over a fixed period of time,
such as a parent education group where the same individuals meet once a
week for 6 weeks." [If not all prevention programs are collecting
pre-post data; please include in a brief narrative, an explanation for
the number of programs included (e.g. sampling and sampling procedures,
or census of all programs collecting pre-post). The number of programs
responding may also reflect the percentage of programs targeting the
specific outcome or risk factor indicated on the form. Therefore please
include in the narrative the percentage of SAPT Block Grant supported
programs targeting that particular outcome]{.underline}. Relevant
narrative information that applies to all reported data should be
provided in a section preceding the reporting forms. If there is
information relevant to only one reporting form, please include it in a
section immediately preceding the relevant form and so indicate.

2\. States are asked to report these data for the most recent State
Fiscal Year (SFY) for which data are available at the time the
application is submitted. In no case should the reporting year be
earlier than the year for which the State reports SAPT block grant
expenditures. Please insert the relevant SFY in the indicated area on
each form.

3\. Please provide as much data as is available for each form.

4\. Pretest data are defined as the data collected from participants at
"intake" at the beginning of the service before they have received the
intervention. Posttest data are defined as the data collected from
participants after completion of the intervention. It would be helpful
to SAMHSA if, in the explanatory narrative, the State would provide a
brief explanation of the range of intervention dosages, e.g., length and
intensity of services included in the programs that data are provided.

5\. State applicants whose data collection systems are unable to report
data in the format requested should contact their State Project Officers
to discuss a suitable way to provide the data.

6\. OPTION: If the State is using a standard statistical package that
yields printouts containing the same information as the reporting forms,
the State may attach the printouts in lieu of the reporting forms.

7\. If possible, please provide the computer files and data tapes along
with the application. This will allow for further analysis at the
national level. Results of such analyses will be shared with the States
and will be used in the development of future Performance Partnership
Grant reporting activities.

**INSERT OVERALL NARRATIVE**: State applicants should include a
discussion of topics relevant to outcome reporting in general. This
would include topics mentioned in instructions above as well as any
additional information (e.g., data infrastructure needs, etc.), the
State deems important.

**INSTRUCTIONS FOR VOLUNTARY FORMS PREVENTION P1 -- P3:**

1\. Include [all]{.underline} "Participants" who received services from
prevention programs that received some or all of their funding from the
Substance Abuse Prevention and Treatment Block Grant.

2\. Participants who received services in the reporting year include
those in prevention programs at any point during the reporting year.

3\. Report data for the most recent State Fiscal Year for which the data
are available at the time the application is submitted. In no case
should the reporting year be earlier than the year for which the State
is reporting SAPT Block Grant expenditures in the application being
submitted. Indicate the State Fiscal Year chosen for reporting in the
appropriate place on the form. The same reporting year is to be used for
all of the voluntary performance measures forms.

4\. On Form Prevention P2, Service Types are those services categorized
in CSAP's Minimum Data Set and Database Builder.

5\. On Form Prevention P3, evidence-based prevention programs are those
programs described in the National Registry of Effective Programs (NREP)
as Model (**I** on Form P3), Effective (**II** on Form P3), or Promising
(**III** on Form P3) Programs. Other evidence-based programs, practices,
policies and strategies (**IV** in Form P3) are those programs
designated by other organizations, (e.g., National Institute on Drug
Abuse, Department of Education, Department of Justice, Center for
Disease Control and Prevention, etc.), as: Best Practices, Principles of
Effectiveness, Science-Based, Evidence-Based, Promising, etc, but have
not gone through the CSAP NREP review process.

NUMBER OF PERSONS SERVED

Count of persons served in

**SAPT Block Grant**

Funded Services

**STATE: REPORTING PERIOD: FROM TO[\_\_\_\_\_\_\_\_\_\_\_]{.underline}**

Persons served in Block Grant funded services include all persons served
in prevention programs that receive all or part of their funding

through the SAPT Block Grant.

<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 17%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td><strong>TOTAL</strong></td>
<td><strong>SINGLE SERVICES</strong></td>
<td><strong>RECURRING SERVICES</strong></td>
<td></td>
<td><strong>TOTAL</strong></td>
<td><strong>SINGLE SERVICES</strong></td>
<td><strong>RECURRING SERVICES</strong></td>
<td></td>
<td><strong>TOTAL</strong></td>
<td><strong>SINGLE SERVICES</strong></td>
<td><strong>RECURRING SERVICES</strong></td>
</tr>
<tr class="even">
<td><strong>AGE</strong></td>
<td colspan="3"></td>
<td><h5 id="raceethnicity">RACE/ETHNICITY</h5></td>
<td></td>
<td></td>
<td></td>
<td><strong>GENDER</strong></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>0-4</strong></td>
<td></td>
<td></td>
<td></td>
<td><p><strong>AMERICAN INDIAN /</strong></p>
<p><strong>ALASKA NATIVE</strong></p></td>
<td></td>
<td></td>
<td></td>
<td><h2 id="female">female </h2></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>5-11</strong></td>
<td></td>
<td></td>
<td></td>
<td><strong>ASIAN</strong></td>
<td></td>
<td></td>
<td></td>
<td><strong>MALE</strong></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>12-14</strong></td>
<td></td>
<td></td>
<td></td>
<td><strong>BLACK/AFRICAN AMERICAN</strong></td>
<td></td>
<td></td>
<td></td>
<td rowspan="8"></td>
<td rowspan="8"></td>
<td rowspan="8"></td>
<td rowspan="8"></td>
</tr>
<tr class="even">
<td><strong>15-17</strong></td>
<td></td>
<td></td>
<td></td>
<td><p><strong>NATIVE HAWAIIAN/</strong></p>
<p><strong>OTHER PACIFIC ISLANDER</strong></p></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>18-20</strong></td>
<td></td>
<td></td>
<td></td>
<td><strong>WHITE</strong></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>21-24</strong></td>
<td></td>
<td></td>
<td></td>
<td><strong>MORE THAN ONE RACE</strong></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>25-44</strong></td>
<td></td>
<td></td>
<td></td>
<td><h1 id="unknown">UNKNOWN</h1></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>45-64</strong></td>
<td></td>
<td></td>
<td></td>
<td><h3 id="total">Total</h3></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="2"><strong>65+</strong></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td><h4 id="not-hispanic-or-latino">Not Hispanic OR Latino</h4></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td><h4 id="hispanic-or-latino">Hispanic OR Latino</h4></td>
</tr>
<tr class="odd">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td><h3 id="total-1">Total</h3></td>
<td></td>
<td></td>
<td></td>
<td><h3 id="total-2">Total</h3></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

  ---------------------- --------------------------- -------------------- ------------- ------------ ------- -- ----------
  **[NUMBER OF SERVICES,                                                                                        
  BY SERVICE                                                                                                    
  TYPES]{.underline}**                                                                                          

  count of services in                                                                                          

  **SAPT Block Grant**                                                                                          

  Funded Services                                                                                               

  **STATE:**                                         **REPORTING PERIOD:                                        
                                                     FROM TO                                                    
                                                     [\_]{.underline}**                                         

  Services include all                                                                                          
  services that are                                                                                             
  funded in part or                                                                                             
  whole through the SAPT                                                                                        
  Block Grant.                                                                                                  

  Service Type                                                            Single        Recurring    Total      

                         STN01:                                                                                 
                         Clearinghouse/Information                                                              
                         Resource Center                                                                        

                         STN02: Health Fairs                                                                    

                         STN03: Health Promotions                                                               

                         STN04: Original A/V                                                                    
                         Material Developed                                                                     

                         STN05: Original Written                                                                
                         Material Developed                                                                     

                         STN06: Original Curricula                                                              
                         Developed                                                                              

                         STN07: Original Periodicals                                                            
                         Developed                                                                              

                         STN08: Original PSA's                                                                  
                         Developed                                                                              

                         STN09: Original Resource                                                               
                         Directories Developed                                                                  

                         STN10: A/V Material                                                                    
                         Disseminated                                                                           

                         STN11: Printed Material                                                                
                         Disseminated                                                                           

                         STN12: Curricula                                                                       
                         Disseminated                                                                           

                         STN13: Periodicals                                                                     
                         Disseminated                                                                           

                         STN14: PSA's Disseminated                                                              

                         STN15: Resource Directories                                                            
                         Disseminated                                                                           

                         STN16: Media Campaigns                                                                 
                         Distributed                                                                            

                         STN17: Speaking Engagement                                                             
                         Attendees                                                                              

                         STN18: Telephone/Email Info                                                            
                         Requests Received                                                                      

                         STE01: COSA Groups                                                                     

                         STE02: Classroom                                                                       
                         Educational Services                                                                   

                         STE03: Educational Services                                                            
                         for Youth Groups                                                                       

                         STE04: Parenting/Family                                                                
                         Management Services                                                                    

                         STE05: Peer Leader/Helper                                                              
                         Programs                                                                               

                         STE06: Small Group Sessions                                                            

                         STA01: ATOD-free                                                                       
                         Social/Recreational Events                                                             

                         STA03: Community Drop-In                                                               
                         Centers                                                                                

                         STA04: Community Drop-In                                                               
                         Center Activities                                                                      

                         STA06: Community Services                                                              

                         STA07: Youth/Adult                                                                     
                         Leadership Functions                                                                   

                         STP01: Employee Assistance                                                             
                         Programs                                                                               

                         STP03: Student Assistance                                                              
                         Programs                                                                               

                         STP05: DUI/SWI/MIP Programs                                                            

                         STP06: Prevention                                                                      
                         Assessment and Referral                                                                

                         STP07: Tobacco Court                                                                   
                         Mandated Programs for Youth                                                            

                         STC01: Accessing Services                                                              
                         and Funding                                                                            

                         STC02: Assessing Community                                                             
                         Needs                                                                                  

                         STC03: Community/Volunteer                                                             
                         Services                                                                               

                         STC04: Formal Community                                                                
                         Teams                                                                                  

                         STC05: Community Team                                                                  
                         Activities                                                                             

                         STC06: Training Services                                                               

                         STC08: Technical Assistance                                                            
                         Services                                                                               

                         STC10: Systematic Planning                                                             
                         Services                                                                               

                         STV01: Environmental                                                                   
                         Consultation to Communities                                                            

                         STV02: Preventing Underage                                                             
                         Sale of Tobacco                                                                        

                         STV03: Preventing Underage                                                             
                         Alcohol Beverage Sales                                                                 

                         STV04: Establishing                                                                    
                         ATOD-Free Policies                                                                     

                         STV05: Changing                                                                        
                         Environmental                                                                          
                         Codes/Ordinances/                                                                      
                         Regulations/Legislation                                                                

                         STV06: Public Policy                                                                   
                         Efforts                                                                                

  TOTAL SERVICES                                                                                                
  ---------------------- --------------------------- -------------------- ------------- ------------ ------- -- ----------

  --------------------------- ----------------------------------------------- --
  **[FORM PREVENTION                                                          
  P3]{.underline}**                                                           

  **[NUMBER OF EVIDENCE-BASED                                                 
  PROGRAMS AND                                                                
  STRATEGIES]{.underline}**                                                   

  Count of programs in                                                        

  **SAPT Block Grant**                                                        

  Funded Services                                                             

  **STATE:**                  **REPORTING PERIOD: FROM TO [\_]{.underline}**  

  Programs include all                                                        
  prevention programs that                                                    
  receive all or part of                                                      
  their funding through the                                                   
  SAPT Block Grant.                                                           
  --------------------------- ----------------------------------------------- --

+---+-----------------+------------+------------+-----------+----------+
| P |                 |            |            |           |          |
| r |                 |            |            |           |          |
| o |                 |            |            |           |          |
| g |                 |            |            |           |          |
| r |                 |            |            |           |          |
| a |                 |            |            |           |          |
| m |                 |            |            |           |          |
| C |                 |            |            |           |          |
| o |                 |            |            |           |          |
| u |                 |            |            |           |          |
| n |                 |            |            |           |          |
| t |                 |            |            |           |          |
| s |                 |            |            |           |          |
| b |                 |            |            |           |          |
| y |                 |            |            |           |          |
| I |                 |            |            |           |          |
| O |                 |            |            |           |          |
| M |                 |            |            |           |          |
| C |                 |            |            |           |          |
| a |                 |            |            |           |          |
| t |                 |            |            |           |          |
| e |                 |            |            |           |          |
| g |                 |            |            |           |          |
| o |                 |            |            |           |          |
| r |                 |            |            |           |          |
| i |                 |            |            |           |          |
| e |                 |            |            |           |          |
| s |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
|   | Program Name    | Universal  | Selective  | Indicated | Total    |
|   | and Source      | P          | P          | Po        |          |
|   |                 | opulations | opulations | pulations |          |
+---+-----------------+------------+------------+-----------+----------+
| # | List NREP Model |            |            |           |          |
| # | Programs (such  |            |            |           |          |
|   | as Project      |            |            |           |          |
|   | Northland or    |            |            |           |          |
| { | Life Skills)    |            |            |           |          |
| # | below.          |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 4 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
| I |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 5 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 6 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 7 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | NREP Model      |            |            |           |          |
| # | Programs        |            |            |           |          |
|   | Subtotal        |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 8 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | List NREP       |            |            |           |          |
| # | Effective       |            |            |           |          |
|   | programs (such  |            |            |           |          |
|   | as Reducing the |            |            |           |          |
| { | Risk or FAN     |            |            |           |          |
| # | club) below.    |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 9 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
| I |                 |            |            |           |          |
| I |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 0 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | NREP Effective  |            |            |           |          |
| # | Programs        |            |            |           |          |
|   | Subtotal        |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 3 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+

+---+-----------------+------------+------------+-----------+----------+
| # | List NREP       |            |            |           |          |
| # | Promising       |            |            |           |          |
|   | programs (such  |            |            |           |          |
|   | as Focus on     |            |            |           |          |
| { | Kids or Brain   |            |            |           |          |
| # | Power) below.   |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 4 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
| I |                 |            |            |           |          |
| I |                 |            |            |           |          |
| I |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 5 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 6 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 7 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | NREP Promising  |            |            |           |          |
| # | Programs        |            |            |           |          |
|   | Subtotal        |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| 8 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | List the names  |            |            |           |          |
| # | and sources of  |            |            |           |          |
|   | other           |            |            |           |          |
|   | evidence-based  |            |            |           |          |
| { | programs,       |            |            |           |          |
| # | practices,      |            |            |           |          |
| s | policies and    |            |            |           |          |
| e | strategies      |            |            |           |          |
| c | below; attach   |            |            |           |          |
| t | additional      |            |            |           |          |
| i | information on  |            |            |           |          |
| o | the program,    |            |            |           |          |
| n | practice,       |            |            |           |          |
| - | policy or       |            |            |           |          |
| 1 | strategy.       |            |            |           |          |
| 9 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
| I |                 |            |            |           |          |
| V |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 0 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 1 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | Other           |            |            |           |          |
| # | Evidence-based  |            |            |           |          |
|   | Programs,       |            |            |           |          |
|   | Practices,      |            |            |           |          |
| { | Policies and    |            |            |           |          |
| # | Strategies      |            |            |           |          |
| s | Subtotal        |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 3 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | Evidence-based  |            |            |           |          |
| # | Programs,       |            |            |           |          |
|   | Practices,      |            |            |           |          |
|   | Policies and    |            |            |           |          |
| { | Strategies      |            |            |           |          |
| # | Subtotal        |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 4 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | List the names  |            |            |           |          |
| # | and sources of  |            |            |           |          |
|   | other           |            |            |           |          |
|   | non             |            |            |           |          |
| { | -evidence-based |            |            |           |          |
| # | programs,       |            |            |           |          |
| s | practices,      |            |            |           |          |
| e | policies and    |            |            |           |          |
| c | strategies      |            |            |           |          |
| t | below; attach   |            |            |           |          |
| i | additional      |            |            |           |          |
| o | information on  |            |            |           |          |
| n | the program,    |            |            |           |          |
| - | practice,       |            |            |           |          |
| 2 | policy or       |            |            |           |          |
| 5 | strategy.       |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
| V |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
|   |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 6 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # |                 |            |            |           |          |
| # |                 |            |            |           |          |
|   |                 |            |            |           |          |
|   |                 |            |            |           |          |
| { |                 |            |            |           |          |
| # |                 |            |            |           |          |
| s |                 |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 7 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+
| # | Non             |            |            |           |          |
| # | -Evidence-based |            |            |           |          |
|   | Programs,       |            |            |           |          |
|   | Practices,      |            |            |           |          |
| { | Policies and    |            |            |           |          |
| # | Strategies      |            |            |           |          |
| s | subtotal        |            |            |           |          |
| e |                 |            |            |           |          |
| c |                 |            |            |           |          |
| t |                 |            |            |           |          |
| i |                 |            |            |           |          |
| o |                 |            |            |           |          |
| n |                 |            |            |           |          |
| - |                 |            |            |           |          |
| 2 |                 |            |            |           |          |
| 8 |                 |            |            |           |          |
| } |                 |            |            |           |          |
+---+-----------------+------------+------------+-----------+----------+

  ---------- -------------------------------------------------------- -----------
  Other                                                               
  Programs                                                            
  Total                                                               

  GRAND                                                               
  TOTAL all                                                           
  programs                                                            
  (NREP and                                                           
  Other)                                                              

             Overall Percent Evidence-Based                           

             Overall Percent Non-Evidence-Based                       
  ---------- -------------------------------------------------------- -----------

**[Form Prevention P4: Perception of Risk/Harm of Substance Use by Those
under Age 21:]{.underline}**

For this measure, calculate the sum of scores for the 4 scale items (see
items below). Calculate this sum at both pretest and posttest. Then
determine the number and percent of participants whose score is
equivalent to 3 or higher on the total of the 4 items (so, a sum of 12
on 4 items is equivalent to 3) at pretest and posttest\*. Report these
numbers in the appropriate boxes in the table. For the change score
column, report the difference (positive or negative) between pretest and
posttest scores (e.g., if 100 youth perceived high risk -- 3 or higher -
at pretest and 120 perceived high risk at posttest, there was a +20
change score, which is equivalent to a 20% improvement). Repeat this
process for the three IOM sub-populations among program participants,
and the demographic sub-populations.

**[Scale Items]{.underline}**:

How much do you think people risk harming themselves (physically or in
other ways) if they: (*no risk, slight risk, moderate risk, great risk*)

> \(1\) take 1 or 2 drinks of an alcoholic beverage (beer, wine, liquor)
> nearly every day?
>
> \(2\) smoke one or more packs of cigarettes per day?
>
> \(3\) try marijuana once or twice?
>
> \(4\) smoke marijuana regularly?

**[\*Pretest/Posttest Guidance]{.underline}**:

Not all interventions lend themselves to matched cases with data
collected at pretest and posttest. For example, environmental
interventions may address an entire community. In the cases that pretest
and posttest data are not feasible, the State should substitute, if
available, other data collected longitudinally (e.g., annual community
surveys).

**[Privacy/Confidentiality]{.underline}**

Reporting of these data is not meant to compromise the confidentiality
of individual program participants. If you believe that your group N's
(number of cases in your table cells) are too small to control for
individual confidentiality, please contact your State Project Officer
for further guidance.

**State**

***Check one line*: Full Census of Participants \_\_\_\_\_\_\_\_\_\_ ;
Sample of Participants \_\_\_\_\_\_\_\_\_**

**\# of Programs\_\_\_\_\_**

**SFY from \_\_\_\_to \_\_\_\_\_** (*Include if different from Federal
fiscal year*)

Form Prevention P4: Perception of Risk/Harm of Substance Use by Those
under Age 21: Report the number and percent who respond "moderate risk"
or "great risk" (add the 2 categories).

<table>
<colgroup>
<col style="width: 10%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="3">Total Population N</td>
<td colspan="3">Total Population %</td>
<td colspan="3">Universal Population N</td>
<td colspan="3">Universal Population %</td>
<td colspan="3">Selective Population N</td>
<td colspan="3">Selective Population %</td>
<td colspan="3">Indicated Population N</td>
<td colspan="3">Indicated Population %</td>
</tr>
<tr class="even">
<td></td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
</tr>
<tr class="odd">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Male</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Female</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>American Indian/</p>
<p>Alaska Native</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Asian</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>Black/</p>
<p>African American</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>Native Hawaiian/</p>
<p>Other Pacific Islander</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>White</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>More Than One Race</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Unknown</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Not Hispanic or Latino</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Hispanic or Latino</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

[Pre N]{.underline} = Number who have used at Pretest. [Post
N]{.underline}= Number who have used at Posttest.

[Pre %]{.underline} = Percent who have used at Pretest. [Post
%]{.underline} = Percent who have used at Posttest.

[Ch Sc N]{.underline} = Number whose use changed for the better
(decreased or remained stable) at Posttest.

[Ch Sc %]{.underline} = Percent whose use changed for the better
(decreased or remained stable) at Posttest.

**[Form Prevention P5: Attitudes toward Substance Use by Those under Age
21:]{.underline}**

For this measure, calculate the sum of scores for the 4 scale items (see
items below). Calculate this sum at both pretest and posttest. Then
determine the number and percent of participants whose score is
equivalent to 3 or higher on the total of the 4 items (so, a sum of 12
on 4 items is equivalent to 3) at pretest and posttest. Report these
numbers in the appropriate boxes in the table. For the change score
column, report the difference (positive or negative) between pretest and
posttest scores (e.g., if 100 youths' attitude toward use was wrong or
very wrong -- 3 or higher - at pretest and 120 youths' attitude toward
use was wrong or very wrong, there was a +20 change score, which is
equivalent to a 20% improvement). Repeat this process for the three IOM
sub-populations among program participants, and the demographic
sub-populations.

Please note that the form now lists multiple age categories. These may
not all be relevant in all cases. For example, if your State funds
programs that serve parents of 0-6 year olds and it is appropriate to
administer the survey items to these parents, you would report the
findings in the 0-6 row. Please report on this measure only for those
age groups that are appropriate for your State.

###### Scale Items

How wrong do you think it is for someone your age to: (*very wrong,
wrong, a little bit wrong, not wrong at all*)

> \(1\) drink beer, wine, or hard liquor (for example, vodka, whiskey or
> gin) regularly?
>
> \(2\) smoke cigarettes?
>
> \(3\) smoke marijuana?
>
> \(4\) use LSD, cocaine, amphetamines or another illegal drug?

**[\*Pretest/Posttest Guidance]{.underline}**:

Not all interventions lend themselves to matched cases with data
collected at pretest and posttest. For example, environmental
interventions may address an entire community. In the cases that pretest
and posttest data are not feasible, the State should substitute, if
available, other data collected longitudinally (e.g., annual community
surveys).

**[Privacy/Confidentiality]{.underline}**

Reporting of these data is not meant to compromise the confidentiality
of individual program participants. If you believe that your group N's
(number of cases in your table cells) are too small to control for
individual confidentiality, please contact your State Project Officer
for further guidance.

**State**

***Check one line*: Full Census of Participants \_\_\_\_\_\_\_\_\_\_ ;
Sample of Participants \_\_\_\_\_\_\_\_\_**

**\# of Programs\_\_\_\_\_**

**SFY from \_\_\_\_to \_\_\_\_\_** (*Include if different from Federal
fiscal year*)

**Form Prevention P5: Attitudes toward Use of Substances by Those under
Age 21: Report the number and percent who respond "wrong" or "very
wrong" (add the 2 categories).**

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="3">Total Population N</td>
<td colspan="3">Total Population %</td>
<td colspan="3">Universal Population N</td>
<td colspan="3">Universal Population %</td>
<td colspan="3">Selective Population N</td>
<td colspan="3">Selective Population %</td>
<td colspan="3">Indicated Population N</td>
<td colspan="3">Indicated Population %</td>
</tr>
<tr class="even">
<td></td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
<td>Pre N</td>
<td>Post N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Post %</td>
<td>Ch Sc</td>
<td>Pre N</td>
<td>Pst N</td>
<td>Ch Sc</td>
<td>Pre %</td>
<td>Pst %</td>
<td>Ch Sc</td>
</tr>
<tr class="odd">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Male</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Female</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>Americn Indian/</p>
<p>Alaska Native</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Asian</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>Black/</p>
<p>African American</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>Native Hawaiian</p>
<p>Other Pacific Islander</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>More Than 1 Race</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>White</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Unknown</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Total</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Not Hispanic or Latino</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Hispanic or Latino</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>0-6</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7-11</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12-17</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>18-20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

[Pre N]{.underline} = Number who have used at Pretest. [Post
N]{.underline}= Number who have used at Posttest.

[Pre %]{.underline} = Percent who have used at Pretest. [Post
%]{.underline} = Percent who have used at Posttest.

[Ch Sc N]{.underline} = Number whose use changed for the better
(decreased or remained stable) at Posttest.

[Ch Sc %]{.underline} = Percent whose use changed for the better
(decreased or remained stable) at Posttest.

**[Form Prevention P6: 30 - Day Substance Use]{.underline}**:

**You will need to duplicate this form for each race/ethnic category.**
We will change the reporting requirements for 30 day substance use
measures at the time of the next application submission, when the PPG
application is developed. This change will reflect a focus on stability
of non-users and decreased use among those who have initiated use. Under
consideration is reporting numbers and percentages of participants whose
use remains stable or decreases as a measure of program success. On
Form, you will continue to report 30 day use as indicated on previous
voluntary prevention forms. This form, shown below, reports pretest and
posttest, mean and standard deviation scores for program participants in
regard to use of several substances (listed on the form).

Report the pretest and post test means and standard deviations, and the
mean differences (and associated level of significance) for 30 day use
scores for each of the substances indicated.

**[\*Pretest/Posttest Guidance]{.underline}**:

Not all interventions lend themselves to matched cases with data
collected at pretest and posttest. For example, environmental
interventions may address an entire community. In the cases that pretest
and posttest data are not feasible, the State should substitute, if
available, other data collected longitudinally (e.g., annual community
surveys).

**[Privacy/Confidentiality]{.underline}**

Reporting of these data is not meant to compromise the confidentiality
of individual program participants. If you believe that your group N's
(number of cases in your table cells) are too small to control for
individual confidentiality, please contact your State Project Officer
for further guidance.

> **State**
>
> ***Check one line*: Full Census of Participants \_\_\_\_\_\_\_\_\_\_ ;
> Sample of Participants \_\_\_\_\_\_\_\_\_ Race/Ethnic
> Group\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\# of Programs\_\_\_\_\_**
>
> SFY from \_\_\_\_to \_\_\_\_\_ (Include if different from Federal
> fiscal year)
>
> **Form Prevention P6: Use of Substances: (Youth): During the past 30
> days, how frequently (often) have you used (taken, had, etc.)**

<table style="width:100%;">
<colgroup>
<col style="width: 13%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2">Age</td>
<td colspan="3"></td>
<td colspan="6">&lt;18</td>
<td colspan="6">18-20</td>
<td colspan="6">&gt;20</td>
</tr>
<tr class="even">
<td colspan="3">Total N</td>
<td colspan="3">M</td>
<td colspan="3">F</td>
<td colspan="3">M</td>
<td colspan="3">F</td>
<td colspan="3">M</td>
<td colspan="3">F</td>
</tr>
<tr class="odd">
<td></td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
<td><p>Pr</p>
<p></p>
<p>SD</p></td>
<td><p>Po</p>
<p></p>
<p>SD</p></td>
<td>T</td>
</tr>
<tr class="even">
<td rowspan="2">Alcohol</td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="2">Tobacco</td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Marijuana</td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Crack or Cocaine</td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Amphet.</td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Inhalant</td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td rowspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

Pr = Pretest. Po= Posttest. M=Male. F=Female.

= Mean. SD = Standard deviation. Ethnicity= Complete this form for a
single ethnic group. Do not combine groups.

Please indicate mean levels of use at pre-test and post-test. T = Please
calculate differences in means and indicate those that are significant.

Source: National Household Survey. Monitoring the Future.

**LIST OF FORMS**

> **1** Face Page
>
> **2** Table of Contents
>
> **3** Funding Agreements/Certifications (PHS 5161)
>
> **4** Substance Abuse State Agency Spending Report
>
> **6** Substance Abuse Entity Inventory
>
> **6A** Prevention Strategy Report
>
> **7A** Treatment Utilization Matrix
>
> **7B** Number of Persons for Alcohol and Other Drug Use in
> State-Funded Services By Age, Sex, Race/Ethnicity (Unduplicated Count)
>
> **8** Treatment Needs Assessment Summary Matrix
>
> **9** Treatment Needs by Age, Sex, and Race/Ethnicity
>
> **11** Intended Use Plan
>
> **12** Treatment Capacity Matrix
>
> **T1** Employment Status
>
> **T2** Living Status
>
> **T3** Criminal Justice Involvement
>
> **T4** Alcohol Use
>
> **T5** Other Drug Use
>
> **T6** Infectious Disease
>
> **T7** Social Support of Recovery
>
> **T8** Retention
>
> **P1** Number of People Served By: Age, Gender, and Race/Ethnicity
>
> **P2** Number of Services, By Service Types
>
> **P3** Number and Percent of Evidenced Based Programs and Strategies
>
> **P4** Perception of Risk/Harm
>
> **P5** Attitudes About Substance Use
>
> **P6** 30-Day Substance Use

+----------------------------------+-----------------------------------+
| #                                |                                   |
| ####### **Uniform Application fo |                                   |
| r FY 2005 Substance Abuse Preven |                                   |
| tion and Treatment Block Grant** |                                   |
+----------------------------------+-----------------------------------+
| State Name:                      |                                   |
+----------------------------------+-----------------------------------+
| **I. State Agency to be the      |                                   |
| Grantee for the Block Grant**    |                                   |
+----------------------------------+-----------------------------------+
| Agency Name:                     |                                   |
+----------------------------------+-----------------------------------+
| Organization Unit:               |                                   |
+----------------------------------+-----------------------------------+
| Mailing Address:                 |                                   |
+----------------------------------+-----------------------------------+
| City:                            | Zip Code:                         |
+----------------------------------+-----------------------------------+
| **II. Contact Person for the     |                                   |
| Grantee of the Block Grant**     |                                   |
+----------------------------------+-----------------------------------+
| Name:                            |                                   |
+----------------------------------+-----------------------------------+
| Agency Name:                     |                                   |
+----------------------------------+-----------------------------------+
| Mailing Address:                 |                                   |
+----------------------------------+-----------------------------------+
| City:                            | Zip Code:                         |
+----------------------------------+-----------------------------------+
| Telephone:                       | Facsimile:                        |
+----------------------------------+-----------------------------------+
| ########                         |                                   |
| #  III. State Expenditure Period |                                   |
+----------------------------------+-----------------------------------+
| From:                            | To:                               |
+----------------------------------+-----------------------------------+
| **IV. Date Submitted**           |                                   |
+----------------------------------+-----------------------------------+
| Date:                            | Original                          |
|                                  |                                   |
|                                  | Revision                          |
+----------------------------------+-----------------------------------+
| **V. Contact Person Responsible  |                                   |
| for Application Submission**     |                                   |
+----------------------------------+-----------------------------------+
| Name:                            | Telephone:                        |
|                                  |                                   |
|                                  | Facsimile: E-Mail:                |
+----------------------------------+-----------------------------------+

+-----------------------------------------------------------------------+
| **ASSURANCES -- NON-CONSTRUCTION PROGRAMS**                           |
+-----------------------------------------------------------------------+
| Public reporting burden for this collection of information is         |
| estimated to average 15 minutes per response, including time for      |
| reviewing instructions, searching existing data sources, gathering    |
| and maintaining the data needed, and completing and reviewing the     |
| collection of information. Send comments regarding the burden         |
| estimate or any other aspect of this collection of information,       |
| including suggestions for reducing this burden, to the Office of      |
| Management and Budget, Paperwork Reduction Project (0348-0040),       |
| Washington, DC 20503.                                                 |
|                                                                       |
| **PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF           |
| MANAGEMENT AND BUDGET.**                                              |
|                                                                       |
| **SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.**         |
+-----------------------------------------------------------------------+
| **Note:** Certain of these assurances may not be applicable to your   |
| project or program. If you have questions, please contact the         |
| awarding agency. Further, certain Federal awarding agencies may       |
| require applicants to certify to additional assurances. If such is    |
| the case, you will be notified.                                       |
|                                                                       |
| As the duly authorized representative of the applicant I certify that |
| the applicant:                                                        |
+-----------------------------------------------------------------------+

+-----------------------------------+---+---+-------------+-------------------+
| 1\. Has the legal authority to    |   |   | > \(e\) the |                   |
| apply for Federal assistance, and |   |   | > Drug      |                   |
| the institutional, managerial and |   |   | > Abuse     |                   |
| financial capability (including   |   |   | > Office    |                   |
| funds sufficient to pay the       |   |   | > and       |                   |
| non-Federal share of project      |   |   | > Treatment |                   |
| costs) to ensure proper planning, |   |   | > Act of    |                   |
| management and completion of the  |   |   | > 1972      |                   |
| project described in this         |   |   | > (P.L.     |                   |
| application.                      |   |   | > 92-255),  |                   |
|                                   |   |   | > as        |                   |
| 2\. Will give the awarding        |   |   | > amended,  |                   |
| agency, the Comptroller General   |   |   | > relating  |                   |
| of the United States, and if      |   |   | > to        |                   |
| appropriate, the State, through   |   |   | > nondis    |                   |
| any authorized representative,    |   |   | crimination |                   |
| access to and the right to        |   |   | > on the    |                   |
| examine all records, books,       |   |   | > basis of  |                   |
| papers, or documents related to   |   |   | > drug      |                   |
| the award; and will establish a   |   |   | > abuse;    |                   |
| proper accounting system in       |   |   | > (f) the   |                   |
| accordance with generally         |   |   | > Co        |                   |
| accepted accounting\              |   |   | mprehensive |                   |
| standard or agency directives.    |   |   | > Alcohol   |                   |
|                                   |   |   | > Abuse and |                   |
| 3\. Will establish safeguards to  |   |   | >           |                   |
| prohibit employees from using     |   |   |  Alcoholism |                   |
| their positions for a purpose     |   |   | >           |                   |
| that constitutes or presents the  |   |   | Prevention, |                   |
| appearance of personal or         |   |   | > Treatment |                   |
| organizational conflict of        |   |   | > and       |                   |
| interest, or personal gain.       |   |   | > Reh       |                   |
|                                   |   |   | abilitation |                   |
| 4\. Will initiate and complete    |   |   | > Act of    |                   |
| the work within the applicable    |   |   | > 1970      |                   |
| time frame after receipt of       |   |   | > (P.L.     |                   |
| approval of the awarding agency.  |   |   | > 91-616),  |                   |
|                                   |   |   | > as        |                   |
| 5\. Will comply with the          |   |   | > amended,  |                   |
| Intergovernmental Personnel Act   |   |   | > relating  |                   |
| of 1970 (42 U.S.C. §§4728-4763)   |   |   | > to        |                   |
| relating to prescribed standards  |   |   | > nondis    |                   |
| for merit systems for programs    |   |   | crimination |                   |
| funded under one of the nineteen  |   |   | > on the    |                   |
| statutes or regulations specified |   |   | > basis of  |                   |
| in Appendix A of OPM's Standard   |   |   | > alcohol   |                   |
| for a Merit System of Personnel   |   |   | > abuse or  |                   |
| Administration (5 C.F.R. 900,     |   |   | >           |                   |
| Subpart F).                       |   |   | alcoholism; |                   |
|                                   |   |   | > (g) §§523 |                   |
| 6\. Will comply with all Federal  |   |   | > and 527   |                   |
| statutes relating to              |   |   | > of the    |                   |
| nondiscrimination. These include  |   |   | > Public    |                   |
| but are not limited to: (a) Title |   |   | > Health    |                   |
| VI of the Civil Rights Act of     |   |   | > Service   |                   |
| 1964 (P.L.88-352) which prohibits |   |   | > Act of    |                   |
| discrimination on the basis of    |   |   | > 1912 (42  |                   |
| race, color or national origin;   |   |   | > U.S.C.    |                   |
| (b) Title IX of the Education     |   |   | > §§290     |                   |
| Amendments of 1972, as amended    |   |   | > dd-3 and  |                   |
| (20 U.S.C. §§1681-1683, and 1685- |   |   | > 290\      |                   |
| 1686), which prohibits            |   |   | > ee-3), as |                   |
| discrimination on the basis of    |   |   | > amended,  |                   |
| sex; (c) Section 504 of the       |   |   | > relating  |                   |
| Rehabilitation Act of 1973, as    |   |   | > to        |                   |
| amended (29 U.S.C. §§794), which  |   |   | > conf      |                   |
| prohibits discrimination on the   |   |   | identiality |                   |
| basis of handicaps; (d) the Age   |   |   | > of        |                   |
| Discrimination Act of 1975, as    |   |   | > alcohol   |                   |
| amended (42 U.S.C. §§6101-6107),  |   |   | > and drug  |                   |
| which prohibits discrimination on |   |   | > abuse     |                   |
| the basis of age;                 |   |   | > patient   |                   |
|                                   |   |   | > records;  |                   |
|                                   |   |   | > (h) Title |                   |
|                                   |   |   | > VIII of   |                   |
|                                   |   |   | > the Civil |                   |
|                                   |   |   | > Rights    |                   |
|                                   |   |   | > Act of    |                   |
|                                   |   |   | > 1968 (42  |                   |
|                                   |   |   | > U.S.C.    |                   |
|                                   |   |   | > §§3601 et |                   |
|                                   |   |   | > seq.), as |                   |
|                                   |   |   | > amended,  |                   |
|                                   |   |   | > relating  |                   |
|                                   |   |   | > to non-   |                   |
|                                   |   |   | > dis       |                   |
|                                   |   |   | crimination |                   |
|                                   |   |   | > in the    |                   |
|                                   |   |   | > sale,     |                   |
|                                   |   |   | > rental or |                   |
|                                   |   |   | > financing |                   |
|                                   |   |   | > of        |                   |
|                                   |   |   | > housing;  |                   |
|                                   |   |   | > (i) any   |                   |
|                                   |   |   | > other     |                   |
|                                   |   |   | > nondis    |                   |
|                                   |   |   | crimination |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  provisions |                   |
|                                   |   |   | > in the    |                   |
|                                   |   |   | > specific  |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  statute(s) |                   |
|                                   |   |   | > under     |                   |
|                                   |   |   | > which     |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | application |                   |
|                                   |   |   | > for       |                   |
|                                   |   |   | > Federal   |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  assistance |                   |
|                                   |   |   | > is being  |                   |
|                                   |   |   | > made; and |                   |
|                                   |   |   | > (j) the   |                   |
|                                   |   |   | > r         |                   |
|                                   |   |   | equirements |                   |
|                                   |   |   | > of any    |                   |
|                                   |   |   | > other     |                   |
|                                   |   |   | > nondis    |                   |
|                                   |   |   | crimination |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  statute(s) |                   |
|                                   |   |   | > which may |                   |
|                                   |   |   | > apply to  |                   |
|                                   |   |   | > the       |                   |
|                                   |   |   | > a         |                   |
|                                   |   |   | pplication. |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | > 7\. Will  |                   |
|                                   |   |   | > comply,   |                   |
|                                   |   |   | > or has    |                   |
|                                   |   |   | > already   |                   |
|                                   |   |   | > complied, |                   |
|                                   |   |   | > with the  |                   |
|                                   |   |   | > r         |                   |
|                                   |   |   | equirements |                   |
|                                   |   |   | > of Title  |                   |
|                                   |   |   | > II and    |                   |
|                                   |   |   | > III of    |                   |
|                                   |   |   | > the       |                   |
|                                   |   |   | > Uniform   |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  Relocation |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  Assistance |                   |
|                                   |   |   | > and Real  |                   |
|                                   |   |   | > Property  |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | Acquisition |                   |
|                                   |   |   | > Policies  |                   |
|                                   |   |   | > Act of    |                   |
|                                   |   |   | > 1970      |                   |
|                                   |   |   | > (P.L.     |                   |
|                                   |   |   | > 91-646)   |                   |
|                                   |   |   | > which     |                   |
|                                   |   |   | > provide   |                   |
|                                   |   |   | > for fair  |                   |
|                                   |   |   | > and       |                   |
|                                   |   |   | > equitable |                   |
|                                   |   |   | > treatment |                   |
|                                   |   |   | > of        |                   |
|                                   |   |   | > persons   |                   |
|                                   |   |   | > displaced |                   |
|                                   |   |   | > or whose  |                   |
|                                   |   |   | > property  |                   |
|                                   |   |   | > is        |                   |
|                                   |   |   | > acquired  |                   |
|                                   |   |   | > as a      |                   |
|                                   |   |   | > result of |                   |
|                                   |   |   | > Federal   |                   |
|                                   |   |   | > or        |                   |
|                                   |   |   | > federally |                   |
|                                   |   |   | > assisted  |                   |
|                                   |   |   | > programs. |                   |
|                                   |   |   | > These     |                   |
|                                   |   |   | > r         |                   |
|                                   |   |   | equirements |                   |
|                                   |   |   | > apply to  |                   |
|                                   |   |   | > all       |                   |
|                                   |   |   | > interests |                   |
|                                   |   |   | > in real   |                   |
|                                   |   |   | > property  |                   |
|                                   |   |   | > acquired  |                   |
|                                   |   |   | > for       |                   |
|                                   |   |   | > project   |                   |
|                                   |   |   | > purposes  |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  regardless |                   |
|                                   |   |   | > of        |                   |
|                                   |   |   | > Federal   |                   |
|                                   |   |   | > pa        |                   |
|                                   |   |   | rticipation |                   |
|                                   |   |   | > in        |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  purchases. |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | > 8\. Will  |                   |
|                                   |   |   | > comply    |                   |
|                                   |   |   | > with the  |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  provisions |                   |
|                                   |   |   | > of the    |                   |
|                                   |   |   | > Hatch Act |                   |
|                                   |   |   | > (5 U.S.C. |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | §§1501-1508 |                   |
|                                   |   |   | > and       |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  7324-7328) |                   |
|                                   |   |   | > which     |                   |
|                                   |   |   | > limit the |                   |
|                                   |   |   | > political |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  activities |                   |
|                                   |   |   | > of        |                   |
|                                   |   |   | > employees |                   |
|                                   |   |   | > whose     |                   |
|                                   |   |   | > principal |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  employment |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  activities |                   |
|                                   |   |   | > are       |                   |
|                                   |   |   | > funded in |                   |
|                                   |   |   | > whole or  |                   |
|                                   |   |   | > in part   |                   |
|                                   |   |   | > with      |                   |
|                                   |   |   | > Federal   |                   |
|                                   |   |   | > funds.    |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | > 9\. Will  |                   |
|                                   |   |   | > comply,   |                   |
|                                   |   |   | > as        |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | applicable, |                   |
|                                   |   |   | > with the  |                   |
|                                   |   |   | >           |                   |
|                                   |   |   |  provisions |                   |
|                                   |   |   | > of the    |                   |
|                                   |   |   | >           |                   |
|                                   |   |   | Davis-Bacon |                   |
|                                   |   |   | > Act (40   |                   |
|                                   |   |   | > U.S.C.    |                   |
|                                   |   |   | > §§276a to |                   |
|                                   |   |   | > 276a-7),  |                   |
|                                   |   |   | > the       |                   |
|                                   |   |   | > Copeland  |                   |
|                                   |   |   | > Act (40   |                   |
|                                   |   |   | > U.S.C.    |                   |
|                                   |   |   | > §276c and |                   |
|                                   |   |   | > 18 U.S.C. |                   |
|                                   |   |   | > §874),    |                   |
|                                   |   |   | > and the   |                   |
|                                   |   |   | > Contract  |                   |
|                                   |   |   | > Work      |                   |
|                                   |   |   | > Hours and |                   |
|                                   |   |   | > Safety    |                   |
|                                   |   |   | > Standards |                   |
|                                   |   |   | > Act (40   |                   |
|                                   |   |   | > U.S.C.    |                   |
|                                   |   |   | > §§327-    |                   |
|                                   |   |   | > 333),     |                   |
|                                   |   |   | > regarding |                   |
|                                   |   |   | > labor     |                   |
|                                   |   |   | > standards |                   |
|                                   |   |   | > for       |                   |
|                                   |   |   | > federally |                   |
|                                   |   |   | > assisted  |                   |
|                                   |   |   | > c         |                   |
|                                   |   |   | onstruction |                   |
|                                   |   |   | > sub       |                   |
|                                   |   |   | agreements. |                   |
+-----------------------------------+---+---+-------------+-------------------+
| 10\. Will comply, if applicable,  |   | > |             |                   |
| with flood insurance purchase     |   |   |             |                   |
| requirements of Section 102(a) of |   | 1 |             |                   |
| the Flood Disaster Protection Act |   | 3 |             |                   |
| of 1973 (P.L. 93-234) which       |   | \ |             |                   |
| requires recipients in a special  |   | . |             |                   |
| flood hazard area to participate  |   | > |             |                   |
| in the program and to purchase    |   |   |             |                   |
| flood insurance if the total cost |   | W |             |                   |
| of insurable construction and     |   | i |             |                   |
| acquisition is \$10,000 or more.  |   | l |             |                   |
|                                   |   | l |             |                   |
| 11\. Will comply with             |   | > |             |                   |
| environmental standards which may |   |   |             |                   |
| be prescribed pursuant to the     |   | a |             |                   |
| following: (a) institution of     |   | s |             |                   |
| environmental quality control     |   | s |             |                   |
| measures under the National       |   | i |             |                   |
| Environmental Policy Act of 1969  |   | s |             |                   |
| (P.L. 91-190) and Executive Order |   | t |             |                   |
| (EO) 11514; (b) notification of   |   | > |             |                   |
| violating facilities pursuant to  |   |   |             |                   |
| EO 11738; (c) protection of       |   | t |             |                   |
| wetland pursuant to EO 11990; (d) |   | h |             |                   |
| evaluation of flood hazards in    |   | e |             |                   |
| floodplains in accordance with EO |   | > |             |                   |
| 11988; (e) assurance of project   |   |   |             |                   |
| consistency with the approved     |   | a |             |                   |
| State management program          |   | w |             |                   |
| developed under the Costal Zone   |   | a |             |                   |
| Management Act of 1972 (16 U.S.C. |   | r |             |                   |
| §§1451 et seq.); (f) conformity   |   | d |             |                   |
| of Federal actions to State       |   | i |             |                   |
| (Clear Air) Implementation Plans  |   | n |             |                   |
| under Section 176(c) of the Clear |   | g |             |                   |
| Air Act of 1955, as amended (42   |   | > |             |                   |
| U.S.C. §§7401 et seq.); (g)       |   |   |             |                   |
| protection of underground sources |   | a |             |                   |
| of drinking water under the Safe  |   | g |             |                   |
| Drinking Water Act of 1974, as    |   | e |             |                   |
| amended, (P.L. 93-523); and (h)   |   | n |             |                   |
| protection of endangered species  |   | c |             |                   |
| under the Endangered Species Act  |   | y |             |                   |
| of 1973, as amended, (P.L.        |   | > |             |                   |
| 93-205).                          |   |   |             |                   |
|                                   |   | i |             |                   |
| 12\. Will comply with the Wild    |   | n |             |                   |
| and Scenic Rivers Act of 1968 (16 |   | > |             |                   |
| U.S.C. §§1271 et seq.) related to |   |   |             |                   |
| protecting components or          |   | a |             |                   |
| potential components of the       |   | s |             |                   |
| national wild and scenic rivers   |   | s |             |                   |
| system.                           |   | u |             |                   |
|                                   |   | r |             |                   |
|                                   |   | i |             |                   |
|                                   |   | n |             |                   |
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|                                   |   | o |             |                   |
|                                   |   | l |             |                   |
|                                   |   | i |             |                   |
|                                   |   | c |             |                   |
|                                   |   | i |             |                   |
|                                   |   | e |             |                   |
|                                   |   | s |             |                   |
|                                   |   | > |             |                   |
|                                   |   |   |             |                   |
|                                   |   | g |             |                   |
|                                   |   | o |             |                   |
|                                   |   | v |             |                   |
|                                   |   | e |             |                   |
|                                   |   | r |             |                   |
|                                   |   | n |             |                   |
|                                   |   | i |             |                   |
|                                   |   | n |             |                   |
|                                   |   | g |             |                   |
|                                   |   | > |             |                   |
|                                   |   |   |             |                   |
|                                   |   | t |             |                   |
|                                   |   | h |             |                   |
|                                   |   | i |             |                   |
|                                   |   | s |             |                   |
|                                   |   | > |             |                   |
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|                                   |   | p |             |                   |
|                                   |   | r |             |                   |
|                                   |   | o |             |                   |
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|                                   |   | . |             |                   |
+-----------------------------------+---+---+-------------+-------------------+
| SIGNATURE OF AUTHORIZED           | T |   |             |                   |
| CERTIFYING OFFICIAL               | I |   |             |                   |
|                                   | T |   |             |                   |
|                                   | L |   |             |                   |
|                                   | E |   |             |                   |
+-----------------------------------+---+---+-------------+-------------------+
|                                   |   |   |             |                   |
|                                   |   |   |             |                   |
|                                   |   |   |             |                   |
|                                   |   |   |             |                   |
|                                   |   |   |             |                   |
+-----------------------------------+---+---+-------------+-------------------+
| APPLICANT ORGANIZATION            |   |   |             | DATE SUBMITTED    |
+-----------------------------------+---+---+-------------+-------------------+
|                                   |   |   |             |                   |
+-----------------------------------+---+---+-------------+-------------------+

CERTIFICATIONS

+-----------------------------------+---------+------------------------+
| **1. CERTIFICATION REGARDING      | > **2.  |                        |
| DEBARMENT AND SUSPENSION**        | >       |                        |
|                                   |  CERTIF |                        |
| > The undersigned (authorized     | ICATION |                        |
| > official signing for the        | > RE    |                        |
| > applicant organization)         | GARDING |                        |
| > certifies to the best of his or | > DR    |                        |
| > her knowledge and belief, that  | UG-FREE |                        |
| > the applicant, defined as the   | > WO    |                        |
| > primary participant in          | RKPLACE |                        |
| > accordance with 45 CFR Part 76, | >       |                        |
| > and its principals:             | REQUIRE |                        |
| >                                 | MENTS** |                        |
| > \(a\) are not presently         | >       |                        |
| > debarred, suspended, proposed   | > The   |                        |
| > for debarment, declared         | > unde  |                        |
| > ineligible, or voluntarily      | rsigned |                        |
| > excluded from covered           | > (aut  |                        |
| > transactions by any Federal     | horized |                        |
| > Department or agency;           | > o     |                        |
| >                                 | fficial |                        |
| > \(b\) have not within a 3-year  | >       |                        |
| > period preceding this proposal  | signing |                        |
| > been convicted of or had a      | > for   |                        |
| > civil judgment rendered against | > the   |                        |
| > them for commission of fraud or | >       |                        |
| > a criminal offense in           | > ap    |                        |
| > connection with obtaining,      | plicant |                        |
| > attempting to obtain, or        | >       |                        |
| > performing a public (Federal,   |  organi |                        |
| > State, or local) transaction or | zation) |                        |
| > contract under a public         | > ce    |                        |
| > transaction; violation of       | rtifies |                        |
| > Federal or State antitrust      | > that  |                        |
| > statutes or commission of       | > the   |                        |
| > embezzlement, theft, forgery,   | > ap    |                        |
| > bribery, falsification or       | plicant |                        |
| > destruction of records, making  | > will, |                        |
| > false statements, or receiving  | > or    |                        |
| > stolen property;                | >       |                        |
| >                                 | > will  |                        |
| > \(c\) are not presently         | > c     |                        |
| > indicted or otherwise           | ontinue |                        |
| > criminally or civilly charged   | > to,   |                        |
| > by a governmental entity        | >       |                        |
| > (Federal, State, or local) with | provide |                        |
| > commission of any of the        | > a     |                        |
| > offenses enumerated in          | > dr    |                        |
| > paragraph (b) of this           | ug-free |                        |
| > certification; and              | > wor   |                        |
| >                                 | k-place |                        |
| > \(d\) have not within a 3-year  | > in    |                        |
| > period preceding this           | >       |                        |
| > application/proposal had one or | > acc   |                        |
| > more public transactions        | ordance |                        |
| > (Federal, State, or local)      | > with  |                        |
| > terminated for cause or         | > 45    |                        |
| > default.                        | > CFR   |                        |
| >                                 | > Part  |                        |
| > Should the applicant not be     | > 76    |                        |
| > able to provide this            | > by:   |                        |
| > certification, an explanation   | >       |                        |
| > as to why should be placed      | > \(a\) |                        |
| > after the assurances page in    | > Pub   |                        |
| > the application package.        | lishing |                        |
| >                                 | > a     |                        |
| > The applicant agrees by         | > st    |                        |
| > submitting this proposal that   | atement |                        |
| > it will include, without        | > no    |                        |
| > modification, the clause titled | tifying |                        |
| > \"Certification Regarding       | > em    |                        |
| > Debarment, Suspension, In       | ployees |                        |
| > eligibility, and Voluntary      | > that  |                        |
| > Exclusion -- Lower Tier Covered | > the   |                        |
| > Transactions\" in all lower     | > u     |                        |
| > tier covered transactions       | nlawful |                        |
| > (i.e., transactions with        | > manuf |                        |
| > sub-grantees and/or             | acture, |                        |
| > contractors) and in all         | >       |                        |
| > solicitations for lower tier    |  distri |                        |
| > covered transactions in         | bution, |                        |
| > accordance with 45 CFR Part 76. | > dis-p |                        |
|                                   | ensing, |                        |
|                                   | > pos   |                        |
|                                   | session |                        |
|                                   | > or    |                        |
|                                   | > use   |                        |
|                                   | > of a  |                        |
|                                   | > con   |                        |
|                                   | trolled |                        |
|                                   | > su    |                        |
|                                   | bstance |                        |
|                                   | > is    |                        |
|                                   | > pro   |                        |
|                                   | hibited |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > gr    |                        |
|                                   | antee's |                        |
|                                   | > wor   |                        |
|                                   | k-place |                        |
|                                   | > and   |                        |
|                                   | > spe   |                        |
|                                   | cifying |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   | actions |                        |
|                                   | > that  |                        |
|                                   | > will  |                        |
|                                   | > be    |                        |
|                                   | > taken |                        |
|                                   | >       |                        |
|                                   | against |                        |
|                                   | > em    |                        |
|                                   | ployees |                        |
|                                   | > for   |                        |
|                                   | > vi    |                        |
|                                   | olation |                        |
|                                   | > of    |                        |
|                                   | > such  |                        |
|                                   | > prohi |                        |
|                                   | bition; |                        |
|                                   | >       |                        |
|                                   | > \(b\) |                        |
|                                   | > Estab |                        |
|                                   | lishing |                        |
|                                   | > an    |                        |
|                                   | >       |                        |
|                                   | ongoing |                        |
|                                   | > dr    |                        |
|                                   | ug-free |                        |
|                                   | > aw    |                        |
|                                   | areness |                        |
|                                   | >       |                        |
|                                   | program |                        |
|                                   | > to    |                        |
|                                   | >       |                        |
|                                   |  inform |                        |
|                                   | > em    |                        |
|                                   | ployees |                        |
|                                   | > about |                        |
|                                   | > --    |                        |
|                                   | >       |                        |
|                                   | > \(1\) |                        |
|                                   | > The   |                        |
|                                   | >       |                        |
|                                   | dangers |                        |
|                                   | > of    |                        |
|                                   | > drug  |                        |
|                                   | > abuse |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > wor   |                        |
|                                   | kplace; |                        |
|                                   | >       |                        |
|                                   | > \(2\) |                        |
|                                   | > The   |                        |
|                                   | > gr    |                        |
|                                   | antee's |                        |
|                                   | >       |                        |
|                                   |  policy |                        |
|                                   | > of    |                        |
|                                   | > main  |                        |
|                                   | taining |                        |
|                                   | > a     |                        |
|                                   | > dr    |                        |
|                                   | ug-free |                        |
|                                   | > wor   |                        |
|                                   | kplace; |                        |
|                                   | >       |                        |
|                                   | > \(3\) |                        |
|                                   | > Any   |                        |
|                                   | > av    |                        |
|                                   | ailable |                        |
|                                   | > drug  |                        |
|                                   | > coun  |                        |
|                                   | seling, |                        |
|                                   | > r     |                        |
|                                   | ehabili |                        |
|                                   | tation, |                        |
|                                   | > and   |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > ass   |                        |
|                                   | istance |                        |
|                                   | > pr    |                        |
|                                   | ograms; |                        |
|                                   | > and   |                        |
|                                   | >       |                        |
|                                   | > \(4\) |                        |
|                                   | > The   |                        |
|                                   | > pe    |                        |
|                                   | nalties |                        |
|                                   | > that  |                        |
|                                   | > may   |                        |
|                                   | > be    |                        |
|                                   | >       |                        |
|                                   | imposed |                        |
|                                   | > upon  |                        |
|                                   | > em    |                        |
|                                   | ployees |                        |
|                                   | > for   |                        |
|                                   | > drug  |                        |
|                                   | > abuse |                        |
|                                   | > vio   |                        |
|                                   | lations |                        |
|                                   | > oc    |                        |
|                                   | curring |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > wor   |                        |
|                                   | kplace; |                        |
|                                   | >       |                        |
|                                   | > \(c\) |                        |
|                                   | >       |                        |
|                                   |  Making |                        |
|                                   | > it a  |                        |
|                                   | > requ  |                        |
|                                   | irement |                        |
|                                   | > that  |                        |
|                                   | > each  |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > to be |                        |
|                                   | >       |                        |
|                                   | engaged |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > perf  |                        |
|                                   | ormance |                        |
|                                   | > of    |                        |
|                                   | > the   |                        |
|                                   | > grant |                        |
|                                   | > be    |                        |
|                                   | > given |                        |
|                                   | > a     |                        |
|                                   | > copy  |                        |
|                                   | > of    |                        |
|                                   | > the   |                        |
|                                   | > st    |                        |
|                                   | atement |                        |
|                                   | > r     |                        |
|                                   | equired |                        |
|                                   | > by    |                        |
|                                   | > pa    |                        |
|                                   | ragraph |                        |
|                                   | > (a)   |                        |
|                                   | >       |                        |
|                                   |  above; |                        |
|                                   | >       |                        |
|                                   | > \(d\) |                        |
|                                   | > No    |                        |
|                                   | tifying |                        |
|                                   | > the   |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > st    |                        |
|                                   | atement |                        |
|                                   | > r     |                        |
|                                   | equired |                        |
|                                   | > by    |                        |
|                                   | > pa    |                        |
|                                   | ragraph |                        |
|                                   | > (a),  |                        |
|                                   | >       |                        |
|                                   |  above, |                        |
|                                   | > that, |                        |
|                                   | > as a  |                        |
|                                   | > co    |                        |
|                                   | ndition |                        |
|                                   | > of    |                        |
|                                   | > emp   |                        |
|                                   | loyment |                        |
|                                   | > under |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   |  grant, |                        |
|                                   | > the   |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > will  |                        |
|                                   | > --    |                        |
|                                   | >       |                        |
|                                   | > \(1\) |                        |
|                                   | > Abide |                        |
|                                   | > by    |                        |
|                                   | > the   |                        |
|                                   | > terms |                        |
|                                   | > of    |                        |
|                                   | > the   |                        |
|                                   | > sta   |                        |
|                                   | tement; |                        |
|                                   | > and   |                        |
|                                   | >       |                        |
|                                   | > \(2\) |                        |
|                                   | >       |                        |
|                                   |  Notify |                        |
|                                   | > the   |                        |
|                                   | > e     |                        |
|                                   | mployer |                        |
|                                   | > in    |                        |
|                                   | >       |                        |
|                                   | writing |                        |
|                                   | > of    |                        |
|                                   | > his   |                        |
|                                   | > or    |                        |
|                                   | > her   |                        |
|                                   | > con   |                        |
|                                   | viction |                        |
|                                   | > for a |                        |
|                                   | > vi    |                        |
|                                   | olation |                        |
|                                   | > of a  |                        |
|                                   | > c     |                        |
|                                   | riminal |                        |
|                                   | > drug  |                        |
|                                   | >       |                        |
|                                   | statute |                        |
|                                   | > oc    |                        |
|                                   | curring |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > wo    |                        |
|                                   | rkplace |                        |
|                                   | > no    |                        |
|                                   | > later |                        |
|                                   | > than  |                        |
|                                   | > five  |                        |
|                                   | > c     |                        |
|                                   | alendar |                        |
|                                   | > days  |                        |
|                                   | > after |                        |
|                                   | > such  |                        |
|                                   | > conv  |                        |
|                                   | iction; |                        |
|                                   | >       |                        |
|                                   | > \(e\) |                        |
|                                   | > No    |                        |
|                                   | tifying |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   |  agency |                        |
|                                   | > in    |                        |
|                                   | >       |                        |
|                                   | writing |                        |
|                                   | >       |                        |
|                                   |  within |                        |
|                                   | > ten   |                        |
|                                   | > c     |                        |
|                                   | alendar |                        |
|                                   | > days  |                        |
|                                   | > after |                        |
|                                   | > re    |                        |
|                                   | ceiving |                        |
|                                   | >       |                        |
|                                   |  notice |                        |
|                                   | > under |                        |
|                                   | > pa    |                        |
|                                   | ragraph |                        |
|                                   | >       |                        |
|                                   |  (d)(2) |                        |
|                                   | > from  |                        |
|                                   | > an    |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > or    |                        |
|                                   | > ot    |                        |
|                                   | herwise |                        |
|                                   | > re    |                        |
|                                   | ceiving |                        |
|                                   | >       |                        |
|                                   |  actual |                        |
|                                   | >       |                        |
|                                   |  notice |                        |
|                                   | > of    |                        |
|                                   | > such  |                        |
|                                   | > conv  |                        |
|                                   | iction. |                        |
|                                   | > Em    |                        |
|                                   | ployers |                        |
|                                   | > of    |                        |
|                                   | > co    |                        |
|                                   | nvicted |                        |
|                                   | > em    |                        |
|                                   | ployees |                        |
|                                   | > must  |                        |
|                                   | >       |                        |
|                                   | provide |                        |
|                                   | >       |                        |
|                                   | notice, |                        |
|                                   | > in    |                        |
|                                   | cluding |                        |
|                                   | > p     |                        |
|                                   | osition |                        |
|                                   | >       |                        |
|                                   |  title, |                        |
|                                   | > to    |                        |
|                                   | > every |                        |
|                                   | > grant |                        |
|                                   | >       |                        |
|                                   | officer |                        |
|                                   | > or    |                        |
|                                   | > other |                        |
|                                   | > d     |                        |
|                                   | esignee |                        |
|                                   | > on    |                        |
|                                   | > whose |                        |
|                                   | > grant |                        |
|                                   | > a     |                        |
|                                   | ctivity |                        |
|                                   | > the   |                        |
|                                   | > co    |                        |
|                                   | nvicted |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > was   |                        |
|                                   | > w     |                        |
|                                   | orking, |                        |
|                                   | >       |                        |
|                                   |  unless |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   | Federal |                        |
|                                   | >       |                        |
|                                   |  agency |                        |
|                                   | > has   |                        |
|                                   | > des   |                        |
|                                   | ignated |                        |
|                                   | > a     |                        |
|                                   | >       |                        |
|                                   | central |                        |
|                                   | > point |                        |
|                                   | > for   |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   | receipt |                        |
|                                   | > of    |                        |
|                                   | > such  |                        |
|                                   | > n     |                        |
|                                   | otices. |                        |
|                                   | >       |                        |
|                                   |  Notice |                        |
|                                   | > shall |                        |
|                                   | >       |                        |
|                                   | include |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   | identif |                        |
|                                   | ication |                        |
|                                   | > nu    |                        |
|                                   | mber(s) |                        |
|                                   | > of    |                        |
|                                   | > each  |                        |
|                                   | > a     |                        |
|                                   | ffected |                        |
|                                   | >       |                        |
|                                   |  grant; |                        |
+-----------------------------------+---------+------------------------+
| > \(f\) Taking one of the         | >       |                        |
| > following actions, within 30    |  person |                        |
| > calendar days of receiving      | > for   |                        |
| > notice under paragraph (d) (2), | > infl  |                        |
| > with respect to any employee    | uencing |                        |
| > who is so convicted --          | > or    |                        |
| >                                 | > att   |                        |
| > \(1\) Taking appropriate        | empting |                        |
| > personnel action against such   | > to    |                        |
| > an employee, up to and          | > in    |                        |
| > including termination,          | fluence |                        |
| > consistent with the             | > an    |                        |
| > requirements of the             | >       |                        |
| > Rehabilitation Act of 1973, as  | officer |                        |
| > amended; or                     | > or    |                        |
| >                                 | > e     |                        |
| > \(2\) Requiring such employee   | mployee |                        |
| > to participate satisfactorily   | > of    |                        |
| > in a drug abuse assistance or   | > any   |                        |
| > rehabilitation program approved | >       |                        |
| > for such purposes by a Federal, | agency, |                        |
| > State, or local health, law     | > a     |                        |
| > enforcement, or other           | >       |                        |
| > appropriate agency;             |  Member |                        |
| >                                 | > of    |                        |
| > \(g\) Making a good faith       | > Co    |                        |
| > effort to continue to maintain  | ngress, |                        |
| > a drug-free workplace through   | > an    |                        |
| > implementation of paragraphs    | >       |                        |
| > (a), (b), (c), (d), (e), and    | officer |                        |
| > (f).                            | > or    |                        |
| >                                 | > e     |                        |
| > For purposes of paragraph (e)   | mployee |                        |
| > regarding agency notification   | > of    |                        |
| > of criminal drug convictions,   | > Co    |                        |
| > the DHHS has designated the     | ngress, |                        |
| > following central point for     | > or an |                        |
| > receipt of such notices:        | > e     |                        |
| >                                 | mployee |                        |
| > Office of Grants and            | > of a  |                        |
| > Acquisition Management          | >       |                        |
| >                                 |  Member |                        |
| > Office of Grants Management     | > of    |                        |
| >                                 | > C     |                        |
| > Office of the Assistant         | ongress |                        |
| > Secretary for Management and    | > in    |                        |
| > Budget                          | > con   |                        |
| >                                 | nection |                        |
| > Department of Health and Human  | > with  |                        |
| > Services                        | > the   |                        |
| >                                 | > a     |                        |
| > 200 Independence Avenue, S.W.,  | warding |                        |
| > Room 517-D                      | > of    |                        |
| >                                 | > any   |                        |
| > Washington, D.C. 20201          | >       |                        |
|                                   | Federal |                        |
| **3. CERTIFICATION REGARDING      | > co    |                        |
| LOBBYING**                        | ntract, |                        |
|                                   | > the   |                        |
| > Title 31, United States Code,   | >       |                        |
| > Section 1352, entitled          |  making |                        |
| > \"Limitation on use of          | > of    |                        |
| > appropriated funds to influence | > any   |                        |
| > certain Federal contracting and | >       |                        |
| > financial transactions,\"       | Federal |                        |
| > generally prohibits recipients  | >       |                        |
| > of Federal grants and           |  grant, |                        |
| > cooperative agreements from     | > the   |                        |
| > using Federal (appropriated)    | >       |                        |
| > funds for lobbying the          |  making |                        |
| > Executive or Legislative        | > of    |                        |
| > Branches of the Federal         | > any   |                        |
| > Government in connection with a | >       |                        |
| > SPECIFIC grant or cooperative   | Federal |                        |
| > agreement. Section 1352 also    | > loan, |                        |
| > requires that each person who   | > the   |                        |
| > requests or receives a Federal  | > e     |                        |
| > grant or cooperative agreement  | ntering |                        |
| > must disclose lobbying          | > into  |                        |
| > undertaken with non-Federal     | > of    |                        |
| > (non-appropriated) funds. These | > any   |                        |
| > requirements apply to grants    | > coop  |                        |
| > and cooperative agreements      | erative |                        |
| > EXCEEDING \$100,000 in total    | > agr   |                        |
| > costs (45 CFR Part 93).         | eement, |                        |
| >                                 | > and   |                        |
| > The undersigned (authorized     | > the   |                        |
| > official signing for the        | > ext   |                        |
| > applicant organization)         | ension, |                        |
| > certifies, to the best of his   | >       |                        |
| > or her knowledge and belief,    |  contin |                        |
| > that:                           | uation, |                        |
| >                                 | > r     |                        |
| > \(1\) No Federal appropriated   | enewal, |                        |
| > funds have been paid or will be | > ame   |                        |
| > paid, by or on behalf of the    | ndment, |                        |
| > under signed, to any            | > or    |                        |
| >                                 | > modif |                        |
| > **5. CERTIFICATION REGARDING**  | ication |                        |
| >                                 | > of    |                        |
| > **ENVIRONMENTAL TOBACCO SMOKE** | > any   |                        |
| >                                 | >       |                        |
| > Public Law 103-227, also known  | Federal |                        |
| > as the Pro-Children Act of 1994 | > co    |                        |
| > (Act), requires that smoking    | ntract, |                        |
| > not be permitted in any portion | >       |                        |
| > of any indoor facility owned or |  grant, |                        |
| > leased or contracted for by an  | > loan, |                        |
| > entity and used routinely or    | > or    |                        |
| > regularly for the provision of  | > coop  |                        |
| > health, day care, early         | erative |                        |
| > childhood development services, | > agr   |                        |
| > education or library services   | eement. |                        |
| > to children under the age of    | >       |                        |
| > 18, if the services are funded  | > \(2\) |                        |
| > by Federal programs either      | > If    |                        |
| > directly or through State or    | > any   |                        |
| > local governments, by Federal   | > funds |                        |
| > grant, contract, loan, or loan  | > other |                        |
| > guarantee. The law also applies | > than  |                        |
| > to children's services that are | > Fe    |                        |
| > provided in indoor facilities   | derally |                        |
| > that are constructed, operated, | > appro |                        |
| > or maintained with such Federal | priated |                        |
| > funds. The law does not apply   | > funds |                        |
| > to children's services provided | > have  |                        |
| > in private residence, portions  | > been  |                        |
| > of facilities used for          | > paid  |                        |
| > inpatient drug or alcohol       | > or    |                        |
| > treatment, service providers    | > will  |                        |
| > whose sole source of applicable | > be    |                        |
| > Federal funds is Medicare or    | > paid  |                        |
| > Medicaid, or facilities where   | > to    |                        |
| > WIC coupons are redeemed.       | > any   |                        |
| >                                 | >       |                        |
| > Failure to comply with the      |  person |                        |
| > provisions of the law may       | > for   |                        |
| > result                          | > infl  |                        |
| >                                 | uencing |                        |
| > in the imposition of a civil    | > or    |                        |
| > monetary penalty of up to       | > att   |                        |
| > \$1,000 for each violation      | empting |                        |
| > and/or the imposition of an     | > to    |                        |
| > administrative compliance order | > in    |                        |
| > on the responsible entity.      | fluence |                        |
|                                   | > an    |                        |
|                                   | >       |                        |
|                                   | officer |                        |
|                                   | > or    |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > of    |                        |
|                                   | > any   |                        |
|                                   | >       |                        |
|                                   | agency, |                        |
|                                   | > a     |                        |
|                                   | >       |                        |
|                                   |  Member |                        |
|                                   | > of    |                        |
|                                   | > Co    |                        |
|                                   | ngress, |                        |
|                                   | > an    |                        |
|                                   | >       |                        |
|                                   | officer |                        |
|                                   | > or    |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > of    |                        |
|                                   | > Co    |                        |
|                                   | ngress, |                        |
|                                   | > or an |                        |
|                                   | > e     |                        |
|                                   | mployee |                        |
|                                   | > of a  |                        |
|                                   | >       |                        |
|                                   |  Member |                        |
|                                   | > of    |                        |
|                                   | > C     |                        |
|                                   | ongress |                        |
|                                   | > in    |                        |
|                                   | > con   |                        |
|                                   | nection |                        |
|                                   | > with  |                        |
|                                   | > this  |                        |
|                                   | >       |                        |
|                                   | Federal |                        |
|                                   | > co    |                        |
|                                   | ntract, |                        |
|                                   | >       |                        |
|                                   |  grant, |                        |
|                                   | > loan, |                        |
|                                   | > or    |                        |
|                                   | > coop  |                        |
|                                   | erative |                        |
|                                   | > agr   |                        |
|                                   | eement, |                        |
|                                   | > the   |                        |
|                                   | > unde  |                        |
|                                   | rsigned |                        |
|                                   | > shall |                        |
|                                   | > c     |                        |
|                                   | omplete |                        |
|                                   | > and   |                        |
|                                   | >       |                        |
|                                   |  submit |                        |
|                                   | > S     |                        |
|                                   | tandard |                        |
|                                   | > Fo    |                        |
|                                   | rm-LLL, |                        |
|                                   | > \"Dis |                        |
|                                   | closure |                        |
|                                   | > of    |                        |
|                                   | > L     |                        |
|                                   | obbying |                        |
|                                   | > Acti  |                        |
|                                   | vities, |                        |
|                                   | > \"in  |                        |
|                                   | > acc   |                        |
|                                   | ordance |                        |
|                                   | > with  |                        |
|                                   | > its   |                        |
|                                   | >       |                        |
|                                   |  instru |                        |
|                                   | ctions. |                        |
|                                   | > (If   |                        |
|                                   | >       |                        |
|                                   | needed, |                        |
|                                   | > S     |                        |
|                                   | tandard |                        |
|                                   | > Fo    |                        |
|                                   | rm-LLL, |                        |
|                                   | > \"Dis |                        |
|                                   | closure |                        |
|                                   | > of    |                        |
|                                   | > L     |                        |
|                                   | obbying |                        |
|                                   | >       |                        |
|                                   |  Activi |                        |
|                                   | ties,\" |                        |
|                                   | > its   |                        |
|                                   | >       |                        |
|                                   |  instru |                        |
|                                   | ctions, |                        |
|                                   | > and   |                        |
|                                   | > conti |                        |
|                                   | nuation |                        |
|                                   | > sheet |                        |
|                                   | > are   |                        |
|                                   | > i     |                        |
|                                   | ncluded |                        |
|                                   | > at    |                        |
|                                   | > the   |                        |
|                                   | > end   |                        |
|                                   | > of    |                        |
|                                   | > this  |                        |
|                                   | > appl  |                        |
|                                   | ication |                        |
|                                   | >       |                        |
|                                   |  form.) |                        |
|                                   | >       |                        |
|                                   | > \(3\) |                        |
|                                   | > The   |                        |
|                                   | > unde  |                        |
|                                   | rsigned |                        |
|                                   | > shall |                        |
|                                   | >       |                        |
|                                   | require |                        |
|                                   | > that  |                        |
|                                   | > the   |                        |
|                                   | > l     |                        |
|                                   | anguage |                        |
|                                   | > of    |                        |
|                                   | > this  |                        |
|                                   | >       |                        |
|                                   |  certif |                        |
|                                   | ication |                        |
|                                   | > be    |                        |
|                                   | > i     |                        |
|                                   | ncluded |                        |
|                                   | > in    |                        |
|                                   | > the   |                        |
|                                   | > award |                        |
|                                   | > do    |                        |
|                                   | cuments |                        |
|                                   | > for   |                        |
|                                   | > all   |                        |
|                                   | > su    |                        |
|                                   | bawards |                        |
|                                   | > at    |                        |
|                                   | > all   |                        |
|                                   | > tiers |                        |
|                                   | > (in   |                        |
|                                   | cluding |                        |
|                                   | >       |                        |
|                                   |  subcon |                        |
|                                   | tracts, |                        |
|                                   | > sub-  |                        |
|                                   | grants, |                        |
|                                   | > and   |                        |
|                                   | > co    |                        |
|                                   | ntracts |                        |
|                                   | > under |                        |
|                                   | >       |                        |
|                                   | grants, |                        |
|                                   | > loans |                        |
|                                   | > and   |                        |
|                                   | > coop  |                        |
|                                   | erative |                        |
|                                   | > agre  |                        |
|                                   | ements) |                        |
|                                   | > and   |                        |
|                                   | > that  |                        |
|                                   | > all   |                        |
|                                   | >       |                        |
|                                   |  subrec |                        |
|                                   | ipients |                        |
|                                   | > shall |                        |
|                                   | >       |                        |
|                                   | certify |                        |
|                                   | > and   |                        |
|                                   | > d     |                        |
|                                   | isclose |                        |
|                                   | > accor |                        |
|                                   | dingly. |                        |
|                                   | >       |                        |
|                                   | > This  |                        |
|                                   | >       |                        |
|                                   |  certif |                        |
|                                   | ication |                        |
|                                   | > is a  |                        |
|                                   | > m     |                        |
|                                   | aterial |                        |
|                                   | >       |                        |
|                                   | represe |                        |
|                                   | ntation |                        |
|                                   | > of    |                        |
|                                   | > fact  |                        |
|                                   | > upon  |                        |
|                                   | > which |                        |
|                                   | > r     |                        |
|                                   | eliance |                        |
|                                   | > was   |                        |
|                                   | >       |                        |
|                                   |  placed |                        |
|                                   | > when  |                        |
|                                   | > this  |                        |
|                                   | > tran  |                        |
|                                   | saction |                        |
|                                   | > was   |                        |
|                                   | > made  |                        |
|                                   | > or    |                        |
|                                   | >       |                        |
|                                   | entered |                        |
|                                   | > into. |                        |
|                                   | > Sub   |                        |
|                                   | mission |                        |
|                                   | > of    |                        |
|                                   | > this  |                        |
|                                   | >       |                        |
|                                   |  certif |                        |
|                                   | ication |                        |
|                                   | > is a  |                        |
|                                   | > prere |                        |
|                                   | quisite |                        |
|                                   | > for   |                        |
|                                   | >       |                        |
|                                   |  making |                        |
|                                   | > or    |                        |
|                                   | > e     |                        |
|                                   | ntering |                        |
|                                   | > into  |                        |
|                                   | > this  |                        |
|                                   | > tran  |                        |
|                                   | saction |                        |
|                                   | >       |                        |
|                                   | imposed |                        |
|                                   | > by    |                        |
|                                   | >       |                        |
|                                   | Section |                        |
|                                   | > 1352, |                        |
|                                   | > U.S.  |                        |
|                                   | > Code. |                        |
|                                   | > Any   |                        |
|                                   | >       |                        |
|                                   |  person |                        |
|                                   | > who   |                        |
|                                   | > fails |                        |
|                                   | > to    |                        |
|                                   | > file  |                        |
|                                   | > the   |                        |
|                                   | > r     |                        |
|                                   | equired |                        |
|                                   | >       |                        |
|                                   |  certif |                        |
|                                   | ication |                        |
|                                   | > shall |                        |
|                                   | > be    |                        |
|                                   | >       |                        |
|                                   | subject |                        |
|                                   | > to a  |                        |
|                                   | > civil |                        |
|                                   | >       |                        |
|                                   | penalty |                        |
|                                   | > of    |                        |
|                                   | > not   |                        |
|                                   | > less  |                        |
|                                   | > than  |                        |
|                                   | > \     |                        |
|                                   | $10,000 |                        |
|                                   | > and   |                        |
|                                   | > not   |                        |
|                                   | > more  |                        |
|                                   | > than  |                        |
|                                   | > \$    |                        |
|                                   | 100,000 |                        |
|                                   | > for   |                        |
|                                   | > each  |                        |
|                                   | > such  |                        |
|                                   | > f     |                        |
|                                   | ailure. |                        |
|                                   | >       |                        |
|                                   | > **4.  |                        |
|                                   | >       |                        |
|                                   |  CERTIF |                        |
|                                   | ICATION |                        |
|                                   | > RE    |                        |
|                                   | GARDING |                        |
|                                   | >       |                        |
|                                   | PROGRAM |                        |
|                                   | > FRAUD |                        |
|                                   | > CIVIL |                        |
|                                   | > R     |                        |
|                                   | EMEDIES |                        |
|                                   | > ACT   |                        |
|                                   | > (P    |                        |
|                                   | FCRA)** |                        |
|                                   | >       |                        |
|                                   | > The   |                        |
|                                   | > unde  |                        |
|                                   | rsigned |                        |
|                                   | > (aut  |                        |
|                                   | horized |                        |
|                                   | > o     |                        |
|                                   | fficial |                        |
|                                   | >       |                        |
|                                   | signing |                        |
|                                   | > for   |                        |
|                                   | > the   |                        |
|                                   | > ap    |                        |
|                                   | plicant |                        |
|                                   | >       |                        |
|                                   |  organi |                        |
|                                   | zation) |                        |
|                                   | > ce    |                        |
|                                   | rtifies |                        |
|                                   | > that  |                        |
|                                   | > the   |                        |
|                                   | > sta   |                        |
|                                   | tements |                        |
|                                   | >       |                        |
|                                   |  herein |                        |
|                                   | > are   |                        |
|                                   | > true, |                        |
|                                   | > co    |                        |
|                                   | mplete, |                        |
|                                   | > and   |                        |
|                                   | > a     |                        |
|                                   | ccurate |                        |
|                                   | > to    |                        |
|                                   | > the   |                        |
|                                   | > best  |                        |
|                                   | > of    |                        |
|                                   | > his   |                        |
|                                   | > or    |                        |
|                                   | > her   |                        |
|                                   | > kno   |                        |
|                                   | wledge, |                        |
|                                   | > and   |                        |
|                                   | > that  |                        |
|                                   | > he or |                        |
|                                   | > she   |                        |
|                                   | > is    |                        |
|                                   | > aware |                        |
|                                   | > that  |                        |
|                                   | > any   |                        |
|                                   | >       |                        |
|                                   |  false, |                        |
|                                   | > fict  |                        |
|                                   | itious, |                        |
|                                   | > or    |                        |
|                                   | > fra   |                        |
|                                   | udulent |                        |
|                                   | > sta   |                        |
|                                   | tements |                        |
|                                   | > or    |                        |
|                                   | >       |                        |
|                                   |  claims |                        |
|                                   | > may   |                        |
|                                   | >       |                        |
|                                   | subject |                        |
|                                   | > him   |                        |
|                                   | > or    |                        |
|                                   | > her   |                        |
|                                   | > to    |                        |
|                                   | > cr    |                        |
|                                   | iminal, |                        |
|                                   | >       |                        |
|                                   |  civil, |                        |
|                                   | > or    |                        |
|                                   | >       |                        |
|                                   | adminis |                        |
|                                   | trative |                        |
|                                   | > pen   |                        |
|                                   | alties. |                        |
|                                   | > The   |                        |
|                                   | > unde  |                        |
|                                   | rsigned |                        |
|                                   | >       |                        |
|                                   |  agrees |                        |
|                                   | > that  |                        |
|                                   | > the   |                        |
|                                   | > ap    |                        |
|                                   | plicant |                        |
|                                   | > organ |                        |
|                                   | ization |                        |
|                                   | > will  |                        |
|                                   | >       |                        |
|                                   |  comply |                        |
|                                   | > with  |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   |  Public |                        |
|                                   | >       |                        |
|                                   |  Health |                        |
|                                   | >       |                        |
|                                   | Service |                        |
|                                   | > terms |                        |
|                                   | > and   |                        |
|                                   | > con   |                        |
|                                   | ditions |                        |
|                                   | > of    |                        |
|                                   | > award |                        |
|                                   | > if a  |                        |
|                                   | > grant |                        |
|                                   | > is    |                        |
|                                   | >       |                        |
|                                   | awarded |                        |
|                                   | > as a  |                        |
|                                   | >       |                        |
|                                   |  result |                        |
|                                   | > of    |                        |
|                                   | > this  |                        |
|                                   | > appli |                        |
|                                   | cation. |                        |
|                                   | >       |                        |
|                                   | > By    |                        |
|                                   | >       |                        |
|                                   | signing |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   | certifi |                        |
|                                   | cation, |                        |
|                                   | > the   |                        |
|                                   | > unde  |                        |
|                                   | rsigned |                        |
|                                   | > ce    |                        |
|                                   | rtifies |                        |
|                                   | > that  |                        |
|                                   | > the   |                        |
|                                   | > ap    |                        |
|                                   | plicant |                        |
|                                   | > organ |                        |
|                                   | ization |                        |
|                                   | > will  |                        |
|                                   | >       |                        |
|                                   |  comply |                        |
|                                   | > with  |                        |
|                                   | > the   |                        |
|                                   | > requi |                        |
|                                   | rements |                        |
|                                   | > of    |                        |
|                                   | > the   |                        |
|                                   | > Act   |                        |
|                                   | > and   |                        |
|                                   | > will  |                        |
|                                   | > not   |                        |
|                                   | > allow |                        |
|                                   | >       |                        |
|                                   | smoking |                        |
|                                   | >       |                        |
|                                   |  within |                        |
|                                   | > any   |                        |
|                                   | >       |                        |
|                                   | portion |                        |
|                                   | > of    |                        |
|                                   | > any   |                        |
|                                   | >       |                        |
|                                   |  indoor |                        |
|                                   | > f     |                        |
|                                   | acility |                        |
|                                   | > used  |                        |
|                                   | > for   |                        |
|                                   | > the   |                        |
|                                   | > pr    |                        |
|                                   | ovision |                        |
|                                   | > of    |                        |
|                                   | > s     |                        |
|                                   | ervices |                        |
|                                   | > for   |                        |
|                                   | > c     |                        |
|                                   | hildren |                        |
|                                   | > as    |                        |
|                                   | >       |                        |
|                                   | defined |                        |
|                                   | > by    |                        |
|                                   | > the   |                        |
|                                   | > Act.  |                        |
|                                   | >       |                        |
|                                   | > The   |                        |
|                                   | > ap    |                        |
|                                   | plicant |                        |
|                                   | > organ |                        |
|                                   | ization |                        |
|                                   | >       |                        |
|                                   |  agrees |                        |
|                                   | > that  |                        |
|                                   | > it    |                        |
|                                   | > will  |                        |
|                                   | >       |                        |
|                                   | require |                        |
|                                   | > that  |                        |
|                                   | > the   |                        |
|                                   | > l     |                        |
|                                   | anguage |                        |
|                                   | > of    |                        |
|                                   | > this  |                        |
|                                   | >       |                        |
|                                   |  certif |                        |
|                                   | ication |                        |
|                                   | > be    |                        |
|                                   | > i     |                        |
|                                   | ncluded |                        |
|                                   | > in    |                        |
|                                   | > any   |                        |
|                                   | > su    |                        |
|                                   | bawards |                        |
|                                   | > which |                        |
|                                   | >       |                        |
|                                   | contain |                        |
|                                   | > pro   |                        |
|                                   | visions |                        |
|                                   | > for   |                        |
|                                   | > chi   |                        |
|                                   | ldren's |                        |
|                                   | > s     |                        |
|                                   | ervices |                        |
|                                   | > and   |                        |
|                                   | > that  |                        |
|                                   | > all   |                        |
|                                   | >       |                        |
|                                   |  subrec |                        |
|                                   | ipients |                        |
|                                   | > shall |                        |
|                                   | >       |                        |
|                                   | certify |                        |
|                                   | > accor |                        |
|                                   | dingly. |                        |
|                                   | >       |                        |
|                                   | > The   |                        |
|                                   | >       |                        |
|                                   |  Public |                        |
|                                   | >       |                        |
|                                   |  Health |                        |
|                                   | > S     |                        |
|                                   | ervices |                        |
|                                   | > s     |                        |
|                                   | trongly |                        |
|                                   | > enc   |                        |
|                                   | ourages |                        |
|                                   | > all   |                        |
|                                   | > grant |                        |
|                                   | > rec   |                        |
|                                   | ipients |                        |
|                                   | > to    |                        |
|                                   | >       |                        |
|                                   | provide |                        |
|                                   | > a     |                        |
|                                   | > smo   |                        |
|                                   | ke-free |                        |
|                                   | > wo    |                        |
|                                   | rkplace |                        |
|                                   | > and   |                        |
|                                   | >       |                        |
|                                   | promote |                        |
|                                   | > the   |                        |
|                                   | >       |                        |
|                                   | non-use |                        |
|                                   | > of    |                        |
|                                   | >       |                        |
|                                   | tobacco |                        |
|                                   | > pr    |                        |
|                                   | oducts. |                        |
|                                   | > This  |                        |
|                                   | > is    |                        |
|                                   | > con   |                        |
|                                   | sistent |                        |
|                                   | > with  |                        |
|                                   | > the   |                        |
|                                   | > PHS   |                        |
|                                   | >       |                        |
|                                   | mission |                        |
|                                   | > to    |                        |
|                                   | >       |                        |
|                                   | protect |                        |
|                                   | > and   |                        |
|                                   | >       |                        |
|                                   | advance |                        |
|                                   | > the   |                        |
|                                   | > p     |                        |
|                                   | hysical |                        |
|                                   | > and   |                        |
|                                   | >       |                        |
|                                   |  mental |                        |
|                                   | >       |                        |
|                                   |  health |                        |
|                                   | > of    |                        |
|                                   | > the   |                        |
|                                   | > A     |                        |
|                                   | merican |                        |
|                                   | >       |                        |
|                                   | people. |                        |
+-----------------------------------+---------+------------------------+
| SIGNATURE OF AUTHORIZED           | > TITLE |                        |
| CERTIFYING OFFICIAL               |         |                        |
+-----------------------------------+---------+------------------------+
| APPLICANT ORGANIZATION            |         | > DATE SUBMITTED       |
+-----------------------------------+---------+------------------------+

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="29"><p><strong>DISCLOSURE OF LOBBYING
ACTIVITIES</strong></p>
<p>Complete this form to disclose lobbying activities pursuant to 31
U.S.C. 1352</p>
<p>(See reverse for public burden disclosure.)</p></td>
</tr>
<tr class="even">
<td colspan="7"><strong>1. Type of Federal Action:</strong></td>
<td colspan="10"><strong>2. Status of Federal Action</strong></td>
<td colspan="12"><strong>3. Report Type:</strong></td>
</tr>
<tr class="odd">
<td></td>
<td> </td>
<td colspan="5" rowspan="4"><p>a. contract</p>
<p>b. grant</p>
<p>c. cooperative agreement</p>
<p>d. loan</p>
<p>e. loan guarantee</p>
<p>f. loan insurance</p></td>
<td></td>
<td colspan="2"> </td>
<td colspan="7" rowspan="4"><p>a. bid/offer/application</p>
<p>b. initial award</p>
<p>c. post-award</p></td>
<td></td>
<td colspan="3"> </td>
<td colspan="8"><p>a. initial filing</p>
<p>b. material change</p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"></td>
<td colspan="3" rowspan="3"></td>
<td colspan="12"><strong>For Material Change Only:</strong></td>
</tr>
<tr class="odd">
<td colspan="6">Year</td>
<td colspan="3">     </td>
<td colspan="2">Quarter</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="10">date of last report</td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="11"><strong>4. Name and Address of Reporting
Entity:</strong></td>
<td colspan="18"><p><strong>5. If Reporting Entity in No. 4 is
Subawardee, Enter Name and</strong></p>
<p><strong>Address of Prime:</strong></p></td>
</tr>
<tr class="even">
<td colspan="11"> Prime Subawardee</td>
<td colspan="18">     </td>
</tr>
<tr class="odd">
<td colspan="4">Tier</td>
<td colspan="2">     </td>
<td colspan="3">, if known:</td>
<td colspan="2">     </td>
<td></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="11" rowspan="3">     </td>
<td colspan="18" rowspan="3"></td>
</tr>
<tr class="odd">
</tr>
<tr class="even">
</tr>
<tr class="odd">
<td colspan="5"><strong>Congressional Distric</strong>t, <em>if
known:</em></td>
<td colspan="6">     </td>
<td></td>
<td colspan="12"><strong>Congressional Distric</strong>t, <em>if
known:</em></td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>6. Federal Department/Agency:</strong></td>
<td colspan="18"><strong>7. Federal Program
Name/Description:</strong></td>
</tr>
<tr class="even">
<td colspan="11" rowspan="2">     </td>
<td colspan="18">     </td>
</tr>
<tr class="odd">
<td colspan="9"><strong>CFDA Numbe</strong>r, <em>if
applicable:</em></td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="9"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>8. Federal Action Number,</strong> if
known:</td>
<td colspan="18"><strong>9. Award Amount,</strong> if known:</td>
</tr>
<tr class="even">
<td colspan="11">     </td>
<td colspan="18">$      </td>
</tr>
<tr class="odd">
<td colspan="11"><p><strong>10. a. Name and Address of Lobbying
Entity</strong></p>
<p><em>(if individual, last name, first name, MI):</em></p></td>
<td colspan="18"><p><strong>b. Individuals Performing Service</strong>s
<em>(including address if different</em></p>
<p><em>from No. 10a.) (last name, first name, MI):</em></p></td>
</tr>
<tr class="even">
<td colspan="11">     </td>
<td colspan="18">     </td>
</tr>
<tr class="odd">
<td colspan="11" rowspan="5"><strong>11. Information requested through
this form is authorized by title 31 U.S.C. section 1352. This disclosure
of lobbying activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction was made or
entered into. This disclosure is required pursuant to 31 U.S.C. 1352.
This information will be reported to the Congress semi-annually and will
be available for public inspection. Any person who fails to file the
required disclosure shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.</strong></td>
<td colspan="3"><strong>Signature:</strong></td>
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Print Name:</strong></td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Title:</strong></td>
<td colspan="16">     </td>
</tr>
<tr class="even">
<td colspan="5"><strong>Telephone No.:</strong></td>
<td colspan="6">     </td>
<td colspan="3"><strong>Date:</strong></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="18"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>F</strong><strong>ederal Use Only:</strong></td>
<td colspan="16">     </td>
<td colspan="10"><p>Authorized for Local Reproduction</p>
<p>Standard Form - LLL (Rev. 7-97)</p></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="16"></td>
<td colspan="10"></td>
</tr>
</tbody>
</table>

+----------+-------------------------------+---+----+------+---+-----+---+
| **DI     |                               |   |    |      |   |     |   |
| SCLOSURE |                               |   |    |      |   |     |   |
| OF       |                               |   |    |      |   |     |   |
| LOBBYING |                               |   |    |      |   |     |   |
| ACTI     |                               |   |    |      |   |     |   |
| VITIES** |                               |   |    |      |   |     |   |
|          |                               |   |    |      |   |     |   |
| **CONT   |                               |   |    |      |   |     |   |
| INUATION |                               |   |    |      |   |     |   |
| SHEET**  |                               |   |    |      |   |     |   |
+----------+-------------------------------+---+----+------+---+-----+---+
| **R      |                               |   | ** |      | * |     |   |
| eporting |                               |   | Pa |      | * |     |   |
| E        |                               |   | ge |      | o |     |   |
| ntity:** |                               |   | ** |      | f |     |   |
|          |                               |   |    |      | * |     |   |
|          |                               |   |    |      | * |     |   |
+----------+-------------------------------+---+----+------+---+-----+---+
|          |                               |   |    |      |   |     |   |
+----------+-------------------------------+---+----+------+---+-----+---+

+-----------------------------------------------------------------------+
| **INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING       |
| ACTIVITIES**                                                          |
|                                                                       |
| This disclosure form shall be completed by the reporting entity,      |
| whether subawardee or prime Federal recipient, at the initiation or   |
| receipt of a covered Federal action, or a material change to a        |
| previous filing, pursuant to title 31 U.S.C. Section 1352. The filing |
| of a form is required for each payment or agreement to make payment   |
| to any lobbying entity for influencing or attempting to influence an  |
| officer or employee of any agency, a Member of Congress, an officer   |
| or employee of Congress, or an employee of a Member of Congress in    |
| connection with a covered Federal action. Use the SF-LLL-A            |
| Continuation Sheet for additional information if the space on the     |
| form is inadequate. Complete all items that apply for both the        |
| initial filing and material change report. Refer to the implementing  |
| guidance published by the Office of Management and Budget for         |
| additional information.                                               |
|                                                                       |
| > 1\. Identify the type of covered Federal action for which lobbying  |
| > activity is and/or has been secured to influence the outcome of a   |
| > covered Federal action.                                             |
| >                                                                     |
| > 2\. Identify the status of the covered Federal action.              |
| >                                                                     |
| > 3\. Identify the appropriate classification of this report. If this |
| > is a follow-up report caused by a material change to the            |
| > information previously reported, enter the year and quarter in      |
| > which the change occurred. Enter the date of the last previously    |
| > submitted report by this reporting entity for this covered Federal  |
| > action.                                                             |
| >                                                                     |
| > 4\. Enter the full name, address, city, state and zip code of the   |
| > reporting entity. Include Congressional District, if known. Check   |
| > the appropriate classification of the reporting entity that         |
| > designates if it is, or expects to be, a prime or subaward          |
| > recipient. Identify the tier of the subawardee, e.g., the first     |
| > subawardee of the prime is the 1st tier. Subawards include but are  |
| > not limited to subcontracts, subgrants and contract awards under    |
| > grants.                                                             |
| >                                                                     |
| > 5\. If the organization filing the report in item 4 checks          |
| > "subawardee", then enter the full name, address, city, state and    |
| > zip code of the prime Federal recipient. Include Congressional      |
| > District, if known.                                                 |
| >                                                                     |
| > 6\. Enter the name of the Federal agency making the award or loan   |
| > commitment. Include at least one organizational level below agency  |
| > name, if known. For example, Department of Transportation, United   |
| > States Coast Guard.                                                 |
| >                                                                     |
| > 7\. Enter the Federal program name or description for the covered   |
| > Federal action (item 1). If known, enter the full Catalog of        |
| > Federal Domestic Assistance (CFDA) number for grants, cooperative   |
| > agreements, loans, and loan commitments.                            |
| >                                                                     |
| > 8\. Enter the most appropriate Federal identifying number available |
| > for the Federal action identified in item 1 \[e.g., Request for     |
| > Proposal (RFP) number; Invitation for Bid (IFB) number; grant       |
| > announcement number; the contract, grant, or loan award number; the |
| > application/proposal control number assigned by the Federal         |
| > agency\]. Include prefixes, e.g., ''RFP-DE-90-001.''                |
| >                                                                     |
| > 9\. For a covered Federal action where there has been an award or   |
| > loan commitment by the Federal agency, enter the Federal amount of  |
| > the award/loan commitment for the prime entity identified in item 4 |
| > or 5.                                                               |
| >                                                                     |
| > 10\. (a) Enter the full name, address, city, state and zip code of  |
| > the lobbying entity engaged by the reporting entity identified in   |
| > item 4 to influence the covered Federal action.                     |
| >                                                                     |
| > \(b\) Enter the full names of the individual(s) performing          |
| > services, and include full address if different from 10(a).         |
| >                                                                     |
| > Enter Last Name, First Name, and Middle Initial (MI).               |
| >                                                                     |
| > 11\. Enter the amount of compensation paid or reasonably expected   |
| > to be paid by the reporting entity (item 4) to the lobbying entity  |
| > (item 10). Indicate whether the payment has been made (actual) or   |
| > will be made (planned). Check all boxes that apply. If this is a    |
| > material change report, enter the cumulative amount of payment made |
| > or planned to be made.                                              |
+-----------------------------------------------------------------------+
| According to the Paperwork Reduction Act, as amended, no persons are  |
| required to respond to a collection of information unless it displays |
| a valid OMB Control Number. The valid OMB control number for this     |
| information collection is OMB No.0348-0046. Public reporting burden   |
| for this collection of information is estimated to average 10 minutes |
| per response, including time for reviewing instructions, searching    |
| existing data sources, gathering and maintaining the data needed, and |
| completing and reviewing the collection of information. Send comments |
| regarding the burden estimate or any other aspect of this collection  |
| of information, including suggestions for reducing this burden, to    |
| the Office of Management and Budget, Paperwork Reduction Project      |
| (0348-0046), Washington, DC 20503.                                    |
+-----------------------------------------------------------------------+

+----------+---+----------------------------------------------+-------+
| # F      |   |                                              |       |
| Y 2005 U |   |                                              |       |
| niform A |   |                                              |       |
| pplicati |   |                                              |       |
| on for t |   |                                              |       |
| he Subst |   |                                              |       |
| ance Abu |   |                                              |       |
| se Preve |   |                                              |       |
| ntion an |   |                                              |       |
| d Treatm |   |                                              |       |
| ent Bloc |   |                                              |       |
| k Grant  |   |                                              |       |
|          |   |                                              |       |
| # T      |   |                                              |       |
| able of  |   |                                              |       |
| Contents |   |                                              |       |
+----------+---+----------------------------------------------+-------+
| # I. Id  |   |                                              |       |
| entifyin |   |                                              |       |
| g Inform |   |                                              |       |
| ation an |   |                                              |       |
| d Assura |   |                                              |       |
| nces Pag |   |                                              |       |
| e number |   |                                              |       |
+----------+---+----------------------------------------------+-------+
| #        | # |                                              | #     |
|  1 {#sec |   |                                              |   {#s |
| tion-29} | F |                                              | ectio |
|          | a |                                              | n-30} |
|          | c |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | P |                                              |       |
|          | a |                                              |       |
|          | g |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | F |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | m |                                              |       |
|          |   |                                              |       |
|          | 1 |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| #        | # |                                              | #     |
|  2 {#sec |   |                                              |   {#s |
| tion-31} | T |                                              | ectio |
|          | a |                                              | n-32} |
|          | b |                                              |       |
|          | l |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | o |                                              |       |
|          | f |                                              |       |
|          |   |                                              |       |
|          | C |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | F |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | m |                                              |       |
|          |   |                                              |       |
|          | 2 |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| #        | # |                                              | #     |
|  3 {#sec |   |                                              |   {#s |
| tion-33} | F |                                              | ectio |
|          | u |                                              | n-34} |
|          | n |                                              |       |
|          | d |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | g |                                              |       |
|          |   |                                              |       |
|          | A |                                              |       |
|          | g |                                              |       |
|          | r |                                              |       |
|          | e |                                              |       |
|          | e |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | s |                                              |       |
|          | / |                                              |       |
|          | C |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | f |                                              |       |
|          | i |                                              |       |
|          | c |                                              |       |
|          | a |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | s |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # | # Chief Executive Officer'                   | #     |
| tion-35} |   | s Funding Agreements/Certifications (Form 3) |   {#s |
|          |   |                                              | ectio |
|          | { |                                              | n-37} |
|          | # |                                              |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | - |                                              |       |
|          | 3 |                                              |       |
|          | 6 |                                              |       |
|          | } |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # | # PHS                                        | #     |
| tion-38} |   | 5161-1 - Certifications Regarding: Debarment |   {#s |
|          |   |  and Suspension; Drug-Free Workplace; Lobbyi | ectio |
|          | { | ng and Disclosure; Program Fraud Civil Remed | n-40} |
|          | # | ies Act (PFCRA); Environmental Tobacco Smoke |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | - |                                              |       |
|          | 3 |                                              |       |
|          | 9 |                                              |       |
|          | } |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # | # Assurances-Non-Construction Programs       | #     |
| tion-41} |   |                                              |   {#s |
|          |   |                                              | ectio |
|          | { |                                              | n-43} |
|          | # |                                              |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | - |                                              |       |
|          | 4 |                                              |       |
|          | 2 |                                              |       |
|          | } |                                              |       |
+----------+---+----------------------------------------------+-------+
| # I      |   |                                              |       |
| I. Actua |   |                                              |       |
| l Use of |   |                                              |       |
|  FY 2002 |   |                                              |       |
|  Substan |   |                                              |       |
| ce Abuse |   |                                              |       |
|  Prevent |   |                                              |       |
| ion and  |   |                                              |       |
| Treatmen |   |                                              |       |
| t Block  |   |                                              |       |
| Grant Fu |   |                                              |       |
| nds and  |   |                                              |       |
|          |   |                                              |       |
| #  Ob    |   |                                              |       |
| ligation |   |                                              |       |
| s of FY  |   |                                              |       |
| 2003 Sub |   |                                              |       |
| stance A |   |                                              |       |
| buse Pre |   |                                              |       |
| vention  |   |                                              |       |
| and Trea |   |                                              |       |
| tment Bl |   |                                              |       |
| ock Gran |   |                                              |       |
| t Funds  |   |                                              |       |
+----------+---+----------------------------------------------+-------+
| #        | * |                                              | #     |
|  1 {#sec | * |                                              |   {#s |
| tion-44} | H |                                              | ectio |
|          | o |                                              | n-45} |
|          | w |                                              |       |
|          | a |                                              |       |
|          | l |                                              |       |
|          | l |                                              |       |
|          | o |                                              |       |
|          | t |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | s |                                              |       |
|          | w |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          | e |                                              |       |
|          | u |                                              |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          | d |                                              |       |
|          | ( |                                              |       |
|          | c |                                              |       |
|          | h |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | k |                                              |       |
|          | l |                                              |       |
|          | i |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
|          | ) |                                              |       |
|          | * |                                              |       |
|          | * |                                              |       |
+----------+---+----------------------------------------------+-------+
| #        | # |                                              | #     |
|  2 {#sec |   |                                              |   {#s |
| tion-46} | H |                                              | ectio |
|          | o |                                              | n-47} |
|          | w |                                              |       |
|          |   |                                              |       |
|          | s |                                              |       |
|          | u |                                              |       |
|          | b |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | c |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | a |                                              |       |
|          | b |                                              |       |
|          | u |                                              |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | f |                                              |       |
|          | u |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | w |                                              |       |
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|          | e |                                              |       |
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|          | u |                                              |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          | d |                                              |       |
|          |   |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          |   |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | e |                                              |       |
|          | d |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | n |                                              |       |
|          | a |                                              |       |
|          | r |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # |                                              | #     |
| tion-48} |   |                                              |   {#s |
|          | A |                                              | ectio |
|          | t |                                              | n-49} |
|          | t |                                              |       |
|          | a |                                              |       |
|          | c |                                              |       |
|          | h |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          |   |                                              |       |
|          | S |                                              |       |
|          | p |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | i |                                              |       |
|          | a |                                              |       |
|          | l |                                              |       |
|          |   |                                              |       |
|          | R |                                              |       |
|          | e |                                              |       |
|          | q |                                              |       |
|          | u |                                              |       |
|          | i |                                              |       |
|          | r |                                              |       |
|          | e |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | s |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | * |                                              | #     |
| chment A | * |                                              |   {#s |
|          | P |                                              | ectio |
|          | r |                                              | n-50} |
|          | e |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | ( |                                              |       |
|          | c |                                              |       |
|          | h |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | k |                                              |       |
|          | l |                                              |       |
|          | i |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
|          | ) |                                              |       |
|          | * |                                              |       |
|          | * |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment B |   |                                              |   {#s |
|          | P |                                              | ectio |
|          | r |                                              | n-51} |
|          | o |                                              |       |
|          | g |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | m |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | f |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          |   |                                              |       |
|          | W |                                              |       |
|          | o |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | n |                                              |       |
|          | a |                                              |       |
|          | r |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment C |   |                                              |   {#s |
|          | P |                                              | ectio |
|          | r |                                              | n-52} |
|          | o |                                              |       |
|          | g |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | m |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | f |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          |   |                                              |       |
|          | I |                                              |       |
|          | V |                                              |       |
|          | D |                                              |       |
|          | U |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | n |                                              |       |
|          | a |                                              |       |
|          | r |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment D |   |                                              |   {#s |
|          | P |                                              | ectio |
|          | r |                                              | n-53} |
|          | o |                                              |       |
|          | g |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | m |                                              |       |
|          |   |                                              |       |
|          | C |                                              |       |
|          | o |                                              |       |
|          | m |                                              |       |
|          | p |                                              |       |
|          | l |                                              |       |
|          | i |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | c |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | M |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | g |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment E |   |                                              |   {#s |
|          | T |                                              | ectio |
|          | B |                                              | n-54} |
|          |   |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          |   |                                              |       |
|          | E |                                              |       |
|          | a |                                              |       |
|          | r |                                              |       |
|          | l |                                              |       |
|          | y |                                              |       |
|          |   |                                              |       |
|          | I |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          |   |                                              |       |
|          | S |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          | v |                                              |       |
|          | i |                                              |       |
|          | c |                                              |       |
|          | e |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | f |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          |   |                                              |       |
|          | H |                                              |       |
|          | I |                                              |       |
|          | V |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment F |   |                                              |   {#s |
|          | G |                                              | ectio |
|          | r |                                              | n-55} |
|          | o |                                              |       |
|          | u |                                              |       |
|          | p |                                              |       |
|          |   |                                              |       |
|          | H |                                              |       |
|          | o |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | E |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | e |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          |   |                                              |       |
|          | P |                                              |       |
|          | r |                                              |       |
|          | o |                                              |       |
|          | g |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | m |                                              |       |
|          | s |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment G |   |                                              |   {#s |
|          | C |                                              | ectio |
|          | a |                                              | n-56} |
|          | p |                                              |       |
|          | a |                                              |       |
|          | c |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | y |                                              |       |
|          |   |                                              |       |
|          | M |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | a |                                              |       |
|          | g |                                              |       |
|          | e |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          |   |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          |   |                                              |       |
|          | W |                                              |       |
|          | a |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | g |                                              |       |
|          |   |                                              |       |
|          | L |                                              |       |
|          | i |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment H |   |                                              |   {#s |
|          | I |                                              | ectio |
|          | n |                                              | n-57} |
|          | d |                                              |       |
|          | e |                                              |       |
|          | p |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          |   |                                              |       |
|          | P |                                              |       |
|          | e |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          |   |                                              |       |
|          | R |                                              |       |
|          | e |                                              |       |
|          | v |                                              |       |
|          | i |                                              |       |
|          | e |                                              |       |
|          | w |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment I |   |                                              |   {#s |
|          | C |                                              | ectio |
|          | h |                                              | n-58} |
|          | a |                                              |       |
|          | r |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | a |                                              |       |
|          | b |                                              |       |
|          | l |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | C |                                              |       |
|          | h |                                              |       |
|          | o |                                              |       |
|          | i |                                              |       |
|          | c |                                              |       |
|          | e |                                              |       |
+----------+---+----------------------------------------------+-------+
| # Atta   | # |                                              | #     |
| chment J |   |                                              |   {#s |
|          | W |                                              | ectio |
|          | a |                                              | n-59} |
|          | i |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | n |                                              |       |
|          | a |                                              |       |
|          | r |                                              |       |
|          | r |                                              |       |
|          | a |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # |                                              | #     |
| tion-60} |   |                                              |   {#s |
|          | S |                                              | ectio |
|          | u |                                              | n-61} |
|          | b |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
|          | a |                                              |       |
|          | n |                                              |       |
|          | c |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | A |                                              |       |
|          | b |                                              |       |
|          | u |                                              |       |
|          | s |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | S |                                              |       |
|          | t |                                              |       |
|          | a |                                              |       |
|          | t |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | A |                                              |       |
|          | g |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | c |                                              |       |
|          | y |                                              |       |
|          |   |                                              |       |
|          | S |                                              |       |
|          | p |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | g |                                              |       |
|          |   |                                              |       |
|          | R |                                              |       |
|          | e |                                              |       |
|          | p |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | t |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | F |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | m |                                              |       |
|          |   |                                              |       |
|          | 4 |                                              |       |
|          | ) |                                              |       |
|          |   |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # |                                              | #     |
| tion-62} |   |                                              |   {#s |
|          | P |                                              | ectio |
|          | r |                                              | n-63} |
|          | i |                                              |       |
|          | m |                                              |       |
|          | a |                                              |       |
|          | r |                                              |       |
|          | y |                                              |       |
|          |   |                                              |       |
|          | P |                                              |       |
|          | r |                                              |       |
|          | e |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          |   |                                              |       |
|          | E |                                              |       |
|          | x |                                              |       |
|          | p |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | u |                                              |       |
|          | r |                                              |       |
|          | e |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | C |                                              |       |
|          | h |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | k |                                              |       |
|          | l |                                              |       |
|          | i |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # |                                              | #     |
| tion-64} |   |                                              |   {#s |
|          | R |                                              | ectio |
|          | e |                                              | n-65} |
|          | s |                                              |       |
|          | o |                                              |       |
|          | u |                                              |       |
|          | r |                                              |       |
|          | c |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | D |                                              |       |
|          | e |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | l |                                              |       |
|          | o |                                              |       |
|          | p |                                              |       |
|          | m |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          |   |                                              |       |
|          | E |                                              |       |
|          | x |                                              |       |
|          | p |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | u |                                              |       |
|          | r |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | C |                                              |       |
|          | h |                                              |       |
|          | e |                                              |       |
|          | c |                                              |       |
|          | k |                                              |       |
|          | l |                                              |       |
|          | i |                                              |       |
|          | s |                                              |       |
|          | t |                                              |       |
+----------+---+----------------------------------------------+-------+
| #        | # |                                              | #     |
|  3 {#sec |   |                                              |   {#s |
| tion-66} | E |                                              | ectio |
|          | n |                                              | n-67} |
|          | t |                                              |       |
|          | i |                                              |       |
|          | t |                                              |       |
|          | y |                                              |       |
|          |   |                                              |       |
|          | I |                                              |       |
|          | n |                                              |       |
|          | v |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | y |                                              |       |
|          |   |                                              |       |
|          | ( |                                              |       |
|          | F |                                              |       |
|          | o |                                              |       |
|          | r |                                              |       |
|          | m |                                              |       |
|          |   |                                              |       |
|          | 6 |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+
| #  {#sec | # |                                              | #     |
| tion-68} |   |                                              |   {#s |
|          | ( |                                              | ectio |
|          | [ |                                              | n-69} |
|          | T |                                              |       |
|          | a |                                              |       |
|          | b |                                              |       |
|          | l |                                              |       |
|          | e |                                              |       |
|          |   |                                              |       |
|          | o |                                              |       |
|          | f |                                              |       |
|          |   |                                              |       |
|          | C |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | e |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | c |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          | t |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | u |                                              |       |
|          | e |                                              |       |
|          | s |                                              |       |
|          |   |                                              |       |
|          | o |                                              |       |
|          | n |                                              |       |
|          |   |                                              |       |
|          | f |                                              |       |
|          | o |                                              |       |
|          | l |                                              |       |
|          | l |                                              |       |
|          | o |                                              |       |
|          | w |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | g |                                              |       |
|          |   |                                              |       |
|          | p |                                              |       |
|          | a |                                              |       |
|          | g |                                              |       |
|          | e |                                              |       |
|          | s |                                              |       |
|          | ] |                                              |       |
|          | { |                                              |       |
|          | . |                                              |       |
|          | u |                                              |       |
|          | n |                                              |       |
|          | d |                                              |       |
|          | e |                                              |       |
|          | r |                                              |       |
|          | l |                                              |       |
|          | i |                                              |       |
|          | n |                                              |       |
|          | e |                                              |       |
|          | } |                                              |       |
|          | . |                                              |       |
|          | ) |                                              |       |
+----------+---+----------------------------------------------+-------+

+----------+--------------------------------------------------+-------+
| # F      |                                                  |       |
| Y 2005 U |                                                  |       |
| niform A |                                                  |       |
| pplicati |                                                  |       |
| on for t |                                                  |       |
| he Subst |                                                  |       |
| ance Abu |                                                  |       |
| se Preve |                                                  |       |
| ntion an |                                                  |       |
| d Treatm |                                                  |       |
| ent Bloc |                                                  |       |
| k Grant  |                                                  |       |
|          |                                                  |       |
| **Table  |                                                  |       |
| of       |                                                  |       |
| Contents |                                                  |       |
| (cont    |                                                  |       |
| inued)** |                                                  |       |
+----------+--------------------------------------------------+-------+
| # I      |                                                  |       |
| I. Actua |                                                  |       |
| l Use of |                                                  |       |
|  FY 2002 |                                                  |       |
|  Substan |                                                  |       |
| ce Abuse |                                                  |       |
|  Prevent |                                                  |       |
| ion and  |                                                  |       |
| Treatmen |                                                  |       |
| t Block  |                                                  |       |
| Grant Fu |                                                  |       |
| nds and  |                                                  |       |
|          |                                                  |       |
| **Obl    |                                                  |       |
| igations |                                                  |       |
| of FY    |                                                  |       |
| 2003     |                                                  |       |
| S        |                                                  |       |
| ubstance |                                                  |       |
| Abuse    |                                                  |       |
| Pr       |                                                  |       |
| evention |                                                  |       |
| and      |                                                  |       |
| T        |                                                  |       |
| reatment |                                                  |       |
| Block    |                                                  |       |
| Grant    |                                                  |       |
| Funds**  |                                                  |       |
+----------+--------------------------------------------------+-------+
|          | **List of entities**                             |       |
+----------+--------------------------------------------------+-------+
|          | **Prevention Strategy Report (Form 6A)**         |       |
+----------+--------------------------------------------------+-------+
| **4**    | ######### Treatment Utilization Matrix (Form 7A) |       |
|          |                                                  |       |
|          | **Number of Persons for Alcohol and Other Drug   |       |
|          | Use in State-Funded Services By Age, Sex,        |       |
|          | Race/Ethnicity (Unduplicated Count) (Form 7B)**  |       |
+----------+--------------------------------------------------+-------+
| **5**    | **Tables I-IV: SSA MOE, TB MOE, HIV MOE and      |       |
|          | Women's Base.**                                  |       |
+----------+--------------------------------------------------+-------+
| **III.   |                                                  |       |
| Intended |                                                  |       |
| Use of   |                                                  |       |
| FY 2005  |                                                  |       |
| S        |                                                  |       |
| ubstance |                                                  |       |
| Abuse    |                                                  |       |
| Pr       |                                                  |       |
| evention |                                                  |       |
| and      |                                                  |       |
| T        |                                                  |       |
| reatment |                                                  |       |
| of Block |                                                  |       |
| Grant    |                                                  |       |
| Funds**  |                                                  |       |
+----------+--------------------------------------------------+-------+
| **1**    | **Planning (narrative)**                         |       |
+----------+--------------------------------------------------+-------+
|          | **Criteria for allocating funds (checklist)**    |       |
+----------+--------------------------------------------------+-------+
| **2**    | **Treatment Needs Assessment Summary Matrix      |       |
|          | (Form 8)**                                       |       |
+----------+--------------------------------------------------+-------+
|          | **Methods for estimation (narrative)**           |       |
+----------+--------------------------------------------------+-------+
| **3**    | **Treatment needs by age, sex, and               |       |
|          | race/ethnicity (Form 9)**                        |       |
+----------+--------------------------------------------------+-------+
|          | **Form 9 for State**                             |       |
+----------+--------------------------------------------------+-------+
|          | **Form 9 for each sub-State planning area**      |       |
+----------+--------------------------------------------------+-------+
| **4**    | ######### Intended use plan                      |       |
+----------+--------------------------------------------------+-------+
|          | **Intended Use Plan (Form 11)**                  |       |
+----------+--------------------------------------------------+-------+
|          | **Primary Prevention Expenditure Checklist**     |       |
+----------+--------------------------------------------------+-------+
|          | **Resource Development Expenditure Checklist**   |       |
+----------+--------------------------------------------------+-------+
| **5**    | **Treatment Capacity**                           |       |
+----------+--------------------------------------------------+-------+
|          | **Treatment Capacity Matrix (Form 12)**          |       |
+----------+--------------------------------------------------+-------+
| **6**    | **Purchasing Services**                          |       |
+----------+--------------------------------------------------+-------+
|          | **Methods for purchasing (checklist)**           |       |
+----------+--------------------------------------------------+-------+
|          | **Methods for determining prices (checklist)**   |       |
+----------+--------------------------------------------------+-------+
| **7**    | **Program Performance Monitoring (checklist)**   |       |
+----------+--------------------------------------------------+-------+

+----------+--------------------------------------------------+--------+
| IV A.    |                                                  |        |
| V        |                                                  |        |
| OLUNTARY |                                                  |        |
| T        |                                                  |        |
| REATMENT |                                                  |        |
| PER      |                                                  |        |
| FORMANCE |                                                  |        |
| MEASURES |                                                  |        |
+----------+--------------------------------------------------+--------+
| **1**    | **VOLUNTARY TREATMENT PERFORMANCE MEASURES**     |        |
+----------+--------------------------------------------------+--------+
|          | **Form T1-Employment Status**                    |        |
+----------+--------------------------------------------------+--------+
|          | **Form T2-Living Status**                        |        |
+----------+--------------------------------------------------+--------+
|          | **Form T3-Criminal Justice Involvement**         |        |
+----------+--------------------------------------------------+--------+
|          | **Form T4-Alcohol Use**                          |        |
+----------+--------------------------------------------------+--------+
|          | **Form T5-Other Drug Use**                       |        |
+----------+--------------------------------------------------+--------+
|          | ######### Form T6-Infectious Disease             |        |
+----------+--------------------------------------------------+--------+
|          | **Form T7-Social Support of Recovery**           |        |
+----------+--------------------------------------------------+--------+
|          | **Form T8-Retention**                            |        |
+----------+--------------------------------------------------+--------+
| #        |                                                  |        |
| ######## |                                                  |        |
|  IV B. V |                                                  |        |
| OLUNTARY |                                                  |        |
|  PREVENT |                                                  |        |
| ION PERF |                                                  |        |
| ORMANCE  |                                                  |        |
| MEASURES |                                                  |        |
+----------+--------------------------------------------------+--------+
| **1**    | **VOLUNTARY PREVENTION PERFORMANCE MEASURES**    |        |
+----------+--------------------------------------------------+--------+
|          | #### Form P1-Number of People Served             |        |
+----------+--------------------------------------------------+--------+
|          | #### Form P2-Number of Services, by Types        |        |
+----------+--------------------------------------------------+--------+
|          | #### Form P3-Number and P                        |        |
|          | ercent of Evidence-based Programs and Strategies |        |
+----------+--------------------------------------------------+--------+
|          | #### Fo                                          |        |
|          | rm P4-Perception of risk/harm (of substance use) |        |
+----------+--------------------------------------------------+--------+
|          | #### Form P5-Attitudes about substance use       |        |
+----------+--------------------------------------------------+--------+
|          | #### Form P6-30 day substance use                |        |
+----------+--------------------------------------------------+--------+

+-----------------------------------------------------------------------+
| ## Uniform Applicat                                                   |
| ion for FY 2005 Substance Abuse Prevention and Treatment Block Grant  |
|                                                                       |
| **Funding Agreements/Certifications**                                 |
|                                                                       |
| **as Required by the Public Health Service (PHS) Act**                |
+-----------------------------------------------------------------------+
| **As part of the annual application for Block Grant funds, it is      |
| required under Title XIX, Part B, Subpart II of the Public Health     |
| Services Ac The PHS Act, as amended, requires the chief executive     |
| officer (or an authorized designee) of the applicant organization to  |
| certify that the State will comply with the following specific        |
| citations as summarized and set forth below, and with any regulations |
| or guidelines issued in conjunction with this Subpart except as       |
| exempt by statute.**                                                  |
|                                                                       |
| We will accept a signature on this form as certification of agreement |
| to comply with the cited provisions of the PHS Act. If signed by a    |
| designee, a copy of the designation must be attached.                 |
+-----------------------------------------------------------------------+
| #### I. Formula Grants to States, Section 1921                        |
+-----------------------------------------------------------------------+
| > **Grant funds will be expended "only for the purpose of planning,   |
| > carrying out, and evaluating activities to prevent and treat        |
| > substance abuse and for related activities" as authorized.**        |
+-----------------------------------------------------------------------+
| ######### II. Certain Allocations, Section 1922                       |
+-----------------------------------------------------------------------+
| -   **Allocations Regarding Primary Prevention Programs, Section      |
|     1922(a)**                                                         |
|                                                                       |
| -   **Allocations Regarding Women, Section 1922(b)**                  |
+-----------------------------------------------------------------------+
| #### III. Intravenous Drug Abuse, Section 1923                        |
+-----------------------------------------------------------------------+
| -   **Capacity of Treatment Programs, Section 1923(a)**               |
|                                                                       |
| -   **Outreach Regarding Intravenous Substance Abuse, Section         |
|     1923(b)**                                                         |
+-----------------------------------------------------------------------+
| #### IV. Requirements                                                 |
| Regarding Tuberculosis and Human Immunodeficiency Virus, Section 1924 |
+-----------------------------------------------------------------------+
| **V. Group Homes for Recovering Substance Abusers, Section 1925**     |
|                                                                       |
| > **Optional from FY 2001 & subsequent fiscal years. Territories as   |
| > described in Section 1925(c) are exempt.**                          |
+-----------------------------------------------------------------------+
| > **The State "has established, and is providing for the ongoing      |
| > operation of a revolving fund" in accordance with Section 1925 of   |
| > the PHS Act, as amended. This requirement is now optional.**        |
+-----------------------------------------------------------------------+
| **VI. State Law Regarding Sale of Tobacco Products to Individuals     |
| Under Age of 18, Section 1926:**                                      |
+-----------------------------------------------------------------------+
| -   **The State has a law in effect making it illegal to sell or      |
|     distribute tobacco products to minors as provided in Section 1926 |
|     (a)(1).**                                                         |
|                                                                       |
| -   **The State will enforce such law in a manner that can reasonably |
|     be expected to reduce the extent to which tobacco products are    |
|     available to individuals under the age of 18 as provided in       |
|     Section 1926 (b)(1).**                                            |
|                                                                       |
| -   **The State will conduct annual, random unannounced inspections   |
|     as prescribed in Section 1926 (b)(2).**                           |
+-----------------------------------------------------------------------+
| #### VII. Treatment Services for Pregnant Women, Section 1927         |
+-----------------------------------------------------------------------+
| > **The State "...will ensure that each pregnant woman in the State   |
| > who seeks or is referred for and would benefit from such services   |
| > is given preference in admission to treatment facilities receiving  |
| > funds pursuant to the grant."**                                     |
+-----------------------------------------------------------------------+
| #### VIII. Additional Agreements, Section 1928                        |
+-----------------------------------------------------------------------+
| -   **Improvement of Process for Appropriate Referrals for Treatment, |
|     Section 1928(a)**                                                 |
|                                                                       |
| -   **Continuing Education, Section 1928(b)**                         |
|                                                                       |
| -   **Coordination of Various Activities and Services, Section        |
|     1928(c)**                                                         |
|                                                                       |
| -   **Waiver of Requirement, Section 1928(d)**                        |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| #### IX. S                                                            |
| ubmission to Secretary of Statewide Assessment of Needs, Section 1929 |
+-----------------------------------------------------------------------+
| ###                                                                   |
| # X. Maintenance of Effort Regarding State Expenditures, Section 1930 |
+-----------------------------------------------------------------------+
| > **With respect to the principal agency of a State, the State "will  |
| > maintain aggregate State expenditures for authorized activities at  |
| > a level that is not less than the average level of such             |
| > expenditures maintained by the State for the 2-year period          |
| > preceding the fiscal year for which the State is applying for the   |
| > grant."**                                                           |
+-----------------------------------------------------------------------+
| **XI. Restrictions on Expenditure of Grant, Section 1931**            |
+-----------------------------------------------------------------------+
| #### XII. Application for Grant; Approval of State Plan, Section 1932 |
+-----------------------------------------------------------------------+
| **XIII. Opportunity for Public Comment on State Plans, Section 1941** |
+-----------------------------------------------------------------------+
| > **The plan required under Section 1932 will be made "public in such |
| > a manner as to facilitate comment from any person (including any    |
| > Federal person or any other public agency) during the development   |
| > of the plan (including any revisions) and after the submission of   |
| > the plan to the Secretary.**                                        |
+-----------------------------------------------------------------------+
| **XIV. Requirement of Reports and Audits by States, Section 1942**    |
+-----------------------------------------------------------------------+
| #### XV. Additional Requirements, Section 1943                        |
+-----------------------------------------------------------------------+
| **XVI. Prohibitions Regarding Receipt of Funds, Section 1946**        |
+-----------------------------------------------------------------------+
| **XVII. Nondiscrimination, Section 1947**                             |
+-----------------------------------------------------------------------+
| **XVIII. Services Provided By Nongovernmental Organizations, Section  |
| 1955**                                                                |
+-----------------------------------------------------------------------+
| > **I hereby certify that the State or Territory will comply with     |
| > Title XIX, Part B, Subpart II and Subpart III of the Public Health  |
| > Service Act, as amended, as summarized above, except for those      |
| > Sections in the Act that do not apply or for which a waiver has     |
| > been granted or may be granted by the Secretary for the period      |
| > covered by this agreement.**                                        |
+-----------------------------------------------------------------------+
| **State:**                                                            |
+-----------------------------------------------------------------------+
| **Name of Chief Executive Officer or Designee:**                      |
+-----------------------------------------------------------------------+
| **Signature of CEO or Designee:**                                     |
+-----------------------------------------------------------------------+
| **Title: Date Signed:**                                               |
|                                                                       |
| **If signed by a designee, a copy of the designation must be          |
| attached**                                                            |
+-----------------------------------------------------------------------+

+--------------+---------+---+-------+--------+-------+-------+--------+
| **[Substance |         |   |       |        |       |       |        |
| Abuse State  |         |   |       |        |       |       |        |
| Agency       |         |   |       |        |       |       |        |
| Spending     |         |   |       |        |       |       |        |
| Report]{.    |         |   |       |        |       |       |        |
| smallcaps}** |         |   |       |        |       |       |        |
|              |         |   |       |        |       |       |        |
| **(Include   |         |   |       |        |       |       |        |
| ONLY funds   |         |   |       |        |       |       |        |
| flowing      |         |   |       |        |       |       |        |
| through your |         |   |       |        |       |       |        |
| agency.)**   |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| State:       |         |   | Dates |        |       |       |        |
|              |         |   | of    |        |       |       |        |
|              |         |   | State |        |       |       |        |
|              |         |   | e     |        |       |       |        |
|              |         |   | xpend |        |       |       |        |
|              |         |   | iture |        |       |       |        |
|              |         |   | pe    |        |       |       |        |
|              |         |   | riod: |        |       |       |        |
|              |         |   | from  |        |       |       |        |
|              |         |   | \_\_  |        |       |       |        |
|              |         |   | \_\_\ |        |       |       |        |
|              |         |   | _\_\_ |        |       |       |        |
|              |         |   | \_\_\ |        |       |       |        |
|              |         |   | _\_\_ |        |       |       |        |
|              |         |   | to    |        |       |       |        |
|              |         |   | \_\_  |        |       |       |        |
|              |         |   | \_\_\ |        |       |       |        |
|              |         |   | _\_\_ |        |       |       |        |
|              |         |   | \_\_\ |        |       |       |        |
|              |         |   | _\_\_ |        |       |       |        |
|              |         |   |       |        |       |       |        |
|              |         |   | (Same |        |       |       |        |
|              |         |   | as    |        |       |       |        |
|              |         |   | Form  |        |       |       |        |
|              |         |   | 1)    |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
|              | # [     |   |       |        |       |       |        |
|              | Source  |   |       |        |       |       |        |
|              | of Fund |   |       |        |       |       |        |
|              | s]{.sma |   |       |        |       |       |        |
|              | llcaps} |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| **           | SAPT    |   | B.    | C.     | D.    | E.    | F.     |
| [Activity]{. | Block   |   | Med   | Other  | State | Local | Other  |
| smallcaps}** | Grant   |   | icaid | F      | funds | funds |        |
|              |         |   |       | ederal |       |       |        |
| (See         |         |   | (Fed  |        |       | (Excl |        |
| instructions |         |   | eral, | funds  |       | uding |        |
| for using    |         |   | S     |        |       | local |        |
| Row 1)       |         |   | tate, | (e.g., |       |       |        |
|              |         |   | and   | Med    |       | Medi  |        |
|              |         |   |       | icare, |       | caid) |        |
|              |         |   | L     | other  |       |       |        |
|              |         |   | ocal) | public |       |       |        |
|              |         |   |       | we     |       |       |        |
|              |         |   |       | lfare) |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
|              | FY 2002 |   |       |        |       |       |        |
|              |         |   |       |        |       |       |        |
|              | Award   |   |       |        |       |       |        |
|              | (spent) |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| 1\.          |         |   |       |        |       |       |        |
| Substance    |         |   |       |        |       |       |        |
| Abuse        |         |   |       |        |       |       |        |
| Treatment    |         |   |       |        |       |       |        |
| and          |         |   |       |        |       |       |        |
| Re           |         |   |       |        |       |       |        |
| habilitation |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| 2\. Primary  |         |   |       |        |       |       |        |
| Prevention   |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| 3\.          |         |   |       |        |       |       |        |
| Tuberculosis |         |   |       |        |       |       |        |
| Services     |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| 4\. HIV      |         |   |       |        |       |       |        |
| Early        |         |   |       |        |       |       |        |
| Intervention |         |   |       |        |       |       |        |
| Services     |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| 5\.          |         |   |       |        |       |       |        |
| Ad           |         |   |       |        |       |       |        |
| ministration |         |   |       |        |       |       |        |
| (excluding   |         |   |       |        |       |       |        |
| prog         |         |   |       |        |       |       |        |
| ram/provider |         |   |       |        |       |       |        |
| level)       |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+
| 6\. Column   |         |   |       |        |       |       |        |
| Total        |         |   |       |        |       |       |        |
+--------------+---------+---+-------+--------+-------+-------+--------+

+----+-----+---------+-----+-------+------+------+------+----------+
|    |     |         |     |       |      |      |      | Page     |
|    |     |         |     |       |      |      |      | \_       |
|    |     |         |     |       |      |      |      | \_\_\_\_ |
|    |     |         |     |       |      |      |      | of       |
|    |     |         |     |       |      |      |      | \_       |
|    |     |         |     |       |      |      |      | \_\_\_\_ |
|    |     |         |     |       |      |      |      | pages    |
+----+-----+---------+-----+-------+------+------+------+----------+
| ## |     |         |     |       |      |      |      |          |
| #  |     |         |     |       |      |      |      |          |
| Su |     |         |     |       |      |      |      |          |
| bs |     |         |     |       |      |      |      |          |
| ta |     |         |     |       |      |      |      |          |
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| En |     |         |     |       |      |      |      |          |
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| en |     |         |     |       |      |      |      |          |
| to |     |         |     |       |      |      |      |          |
| ry |     |         |     |       |      |      |      |          |
|    |     |         |     |       |      |      |      |          |
| (  |     |         |     |       |      |      |      |          |
| Co |     |         |     |       |      |      |      |          |
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| te |     |         |     |       |      |      |      |          |
| c  |     |         |     |       |      |      |      |          |
| ol |     |         |     |       |      |      |      |          |
| um |     |         |     |       |      |      |      |          |
| ns |     |         |     |       |      |      |      |          |
| 1  |     |         |     |       |      |      |      |          |
| -3 |     |         |     |       |      |      |      |          |
| fi |     |         |     |       |      |      |      |          |
| rs |     |         |     |       |      |      |      |          |
| t. |     |         |     |       |      |      |      |          |
| Th |     |         |     |       |      |      |      |          |
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| co |     |         |     |       |      |      |      |          |
| mp |     |         |     |       |      |      |      |          |
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| c  |     |         |     |       |      |      |      |          |
| ol |     |         |     |       |      |      |      |          |
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| ns |     |         |     |       |      |      |      |          |
| 4  |     |         |     |       |      |      |      |          |
| -9 |     |         |     |       |      |      |      |          |
| f  |     |         |     |       |      |      |      |          |
| or |     |         |     |       |      |      |      |          |
| ea |     |         |     |       |      |      |      |          |
| ch |     |         |     |       |      |      |      |          |
| e  |     |         |     |       |      |      |      |          |
| nt |     |         |     |       |      |      |      |          |
| ry |     |         |     |       |      |      |      |          |
| .) |     |         |     |       |      |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
| St |     |         |     |       | --   |      |      |          |
| at |     |         |     |       | ---- |      |      |          |
| e: |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | FY   |      |      |          |
|    |     |         |     |       | 2002 |      |      |          |
|    |     |         |     |       | A    |      |      |          |
|    |     |         |     |       | ward |      |      |          |
|    |     |         |     |       | ---  |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
|    |     |         |     |       | ---- |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
| 1  | 2\. | 3\.     | 4\. | 5\.   | 6\.  | 7\.  | 8\.  | 9\. SAPT |
| \. | Na  | Area    | S   | State | SAPT | SAPT | E    | Block    |
| En | tio | Served  | APT | Funds | B    | B    | arly | Grant    |
| ti | nal | 99-St   | Bl  |       | lock | lock | Inte | Funds    |
| ty | Re  | atewide | ock | (     | G    | G    | rven | for      |
|    | gis | or      | Gr  | Spent | rant | rant | tion | Services |
| Nu | ter | Enter   | ant | d     | F    | F    | Serv | for      |
| mb |     | Su      |     | uring | unds | unds | ices | Pregnant |
| er | (I  | b-State | FY  | State | for  | for  | for  | Women    |
|    | -SA | Area    | 2   | E     | S    | Pri  | HIV  | and      |
|    | TS) | Code    | 002 | xpend | ubst | mary |      | Women    |
|    | ID  |         |     | iture | ance | Pr   | (If  | with     |
|    | M   | (Enter  |     | Per   | A    | even | App  | D        |
|    | ark | only    |     | iod.) | buse | tion | lica | ependent |
|    | \[  | one SPA |     |       | Pr   |      | ble) | Children |
|    | X\] | Per     |     |       | even |      |      |          |
|    |     | Line)   |     |       | tion |      |      |          |
|    | box |         |     |       | and  |      |      |          |
|    | if  |         |     |       | T    |      |      |          |
|    | no  |         |     |       | reat |      |      |          |
|    | ID  |         |     |       | ment |      |      |          |
|    |     |         |     |       | Serv |      |      |          |
|    |     |         |     |       | ices |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
|    | \[  |         |     |       |      |      |      |          |
|    | \]  |         |     |       |      |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
|    | \[  |         |     |       |      |      |      |          |
|    | \]  |         |     |       |      |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
|    | \[  |         |     |       |      |      |      |          |
|    | \]  |         |     |       |      |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
|    | \[  |         |     |       |      |      |      |          |
|    | \]  |         |     |       |      |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+
|    | \[  |         |     |       |      |      |      |          |
|    | \]  |         |     |       |      |      |      |          |
+----+-----+---------+-----+-------+------+------+------+----------+

+----------------+----------+----------------------+------------------+
| ***Risk        |          |                      |                  |
| -Strategies*** |          |                      |                  |
+================+==========+======================+==================+
| **State:**     |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Column A     |          | **Column B           | **Column C       |
| (Risks)**      |          | (Strategies)**       | (Providers)**    |
+----------------+----------+----------------------+------------------+
| ##             |          |                      |                  |
|  {#section-70} |          |                      |                  |
|                |          |                      |                  |
| ## Childre     |          |                      |                  |
| n of Substance |          |                      |                  |
|  Abusers \[1\] |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Pregnant     |          |                      |                  |
| Women / Teens  |          |                      |                  |
| \[2\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Drop-Outs    |          |                      |                  |
| \[3\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Violent and  |          |                      |                  |
| Delinquent     |          |                      |                  |
| Behavior       |          |                      |                  |
| \[4\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Mental       |          |                      |                  |
| Health         |          |                      |                  |
| Problems       |          |                      |                  |
| \[5\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Economically |          |                      |                  |
| Disadvantaged  |          |                      |                  |
| \[6\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Physically   |          |                      |                  |
| Disabled       |          |                      |                  |
| \[7\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Abuse        |          |                      |                  |
| Victims        |          |                      |                  |
| \[8\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Already      |          |                      |                  |
| Using          |          |                      |                  |
| Substances     |          |                      |                  |
| \[9\]**        |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Homeless     |          |                      |                  |
| and/or Runaway |          |                      |                  |
| Youth \[10\]** |          |                      |                  |
+----------------+----------+----------------------+------------------+
| **Other,       |          |                      |                  |
| Specify        |          |                      |                  |
| \[11\]**       |          |                      |                  |
+----------------+----------+----------------------+------------------+

<table style="width:100%;">
<colgroup>
<col style="width: 10%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="16"><p><strong>STATE: Dates of State expenditure period
from _____ to _____ (Same as Form 01)</strong></p>
<h4 id="section-71"></h4></td>
</tr>
<tr class="even">
<td colspan="16"><h4 id="treatment-utilization-matrix">Treatment
Utilization Matrix</h4></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="3"><strong>Primary Diagnosis of Alcohol
Problems</strong></td>
<td colspan="4"><strong>Primary Diagnosis of Drug Problems</strong></td>
<td colspan="5"><p><strong>Substance Abuse Problems</strong></p>
<p><strong>(no primary diagnosis)</strong></p></td>
<td colspan="2"><strong>State-validated Count</strong></td>
</tr>
<tr class="even">
<td rowspan="2">TYPE OF CARE</td>
<td rowspan="2"><p>A. Number of State</p>
<p>Approved Facilities (Service Delivery Units)</p></td>
<td rowspan="2"><p>B. Number</p>
<p>of Admissions</p></td>
<td rowspan="2"><p>C. Number of</p>
<p>Persons Served</p></td>
<td rowspan="2"><p>D. Cost per Person</p>
<p>(Minimum – Maximum)</p></td>
<td rowspan="2"><p>E. Number</p>
<p>of Admissions</p></td>
<td rowspan="2">F. Number of Persons Served</td>
<td colspan="2" rowspan="2"><p>G. Cost per Person</p>
<p>(Minimum – Maximum)</p></td>
<td colspan="2" rowspan="2">H. Number of Admissions</td>
<td colspan="2" rowspan="2">I. Number of Persons Served</td>
<td rowspan="2"><p>J. Cost per Person</p>
<p>(Minimum – Maximum)</p></td>
<td colspan="2">K. (Check one box)</td>
</tr>
<tr class="odd">
<td>Yes</td>
<td>No</td>
</tr>
<tr class="even">
<td colspan="16"><strong>DETOXIFICATION (24-HOUR CARE)</strong></td>
</tr>
<tr class="odd">
<td>1. Hospital Inpatient</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2. Free-Standing Residential</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="16"><h2 id="rehabilitation-residential-1">REHABILITATION/
RESIDENTIAL</h2></td>
</tr>
<tr class="even">
<td>3. Hospital Inpatient</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4. Short-term (up to 30 days)</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5. Long-term (over 30 days)</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="16"><h2 id="ambulatory-outpatient">AMBULATORY
(Outpatient)</h2></td>
</tr>
<tr class="even">
<td>6. Methadone</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7. Non-Methadone</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>8. Intensive Outpatient</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>9. Detoxification</td>
<td></td>
<td></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>TOTAL</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="21"></td>
</tr>
<tr class="even">
<td colspan="21"><h3
id="number-of-persons-for-alcohol-and-other-drug-use-in-state-funded-services">Number
of Persons for Alcohol and Other Drug Use in State-Funded Services</h3>
<h3 id="by-age-sex-and-raceethnicity">by Age, Sex, and
Race/Ethnicity</h3>
<p>(Unduplicated Count)</p></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>State:</strong></td>
<td colspan="16"></td>
</tr>
<tr class="even">
<td colspan="21"><strong><span class="smallcaps">Sex and
Race/Ethnicity</span></strong></td>
</tr>
<tr class="odd">
<td rowspan="2"><strong><span class="smallcaps">Age</span></strong></td>
<td rowspan="2"><strong><span class="smallcaps">A.
TOTAL</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">B.
WHITE</span></strong></td>
<td colspan="3"><strong><span class="smallcaps">C.
BLACK</span></strong></td>
<td colspan="2"><p><strong><span class="smallcaps">D. NATIVE HAWAIIAN
/OTHER</span></strong></p>
<p><strong><span class="smallcaps">PACIFIC
ISLANDER</span></strong></p></td>
<td colspan="2"><strong><span class="smallcaps">E.
ASIAN</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">F. AMERICAN INDIAN /
ALASKA NATIVE</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">G. MORE THAN ONE RACE
REPORTED</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">H.
UNKNOWN</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">I. NOT HISPANIC OR
LATINO</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">J. HISPANIC OR
LATINO</span></strong></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">1. 11 and under</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">2. 12 – 14</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">3. 15 - 17</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">4. 18 - 24</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">5. 25 – 44</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">6. 45 – 64</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">7. 65 and over</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">8. Total</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">9. Pregnant
Women</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 12%" />
<col style="width: 11%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="15"><strong><span class="smallcaps">Treatment Needs
Assessment Summary Matrix</span></strong></td>
</tr>
<tr class="odd">
<td colspan="3">State:</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3">Calendar Year _______</td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="2"><p><strong><span class="smallcaps">1.
Substate</span></strong></p>
<p><strong><span class="smallcaps">planning</span></strong></p>
<p><strong><span class="smallcaps">area</span></strong></p></td>
<td rowspan="2"><p>2. Total</p>
<p>population</p></td>
<td colspan="2"><p>3. Total</p>
<p>population</p>
<p>in need</p></td>
<td colspan="2"><p>4. Number of</p>
<p>IVDUs</p>
<p>in need</p></td>
<td colspan="2"><p>5. Number of</p>
<p>women</p>
<p>in need</p></td>
<td colspan="3"><p>6. Prevalence of</p>
<p>substance-related</p>
<p>criminal activity</p></td>
<td colspan="4"><p>7. Incidence of</p>
<p>communicable</p>
<p>diseases</p></td>
</tr>
<tr class="odd">
<td><p>A.</p>
<p>Needing</p>
<p>treatment</p>
<p>services</p></td>
<td><p>B.</p>
<p>That</p>
<p>would</p>
<p>seek</p>
<p>treatment</p></td>
<td><p>A.</p>
<p>Needing</p>
<p>treatment</p>
<p>services</p></td>
<td><p>B.</p>
<p>That</p>
<p>would</p>
<p>seek</p>
<p>treatment</p></td>
<td><p>A.</p>
<p>Needing</p>
<p>treatment</p>
<p>services</p></td>
<td><p>B.</p>
<p>That</p>
<p>would</p>
<p>seek</p>
<p>treatment</p></td>
<td><p>A.</p>
<p>Number of DWI arrests</p></td>
<td><p>B.</p>
<p>Number of drug-related arrests</p></td>
<td><p>C.</p>
<p>Other</p>
<p>(specify):</p>
<p>_________</p></td>
<td><p>A.</p>
<p>Hepatitis B/</p>
<p>100,000</p></td>
<td><p>B.</p>
<p>AIDS/</p>
<p>100,000</p></td>
<td colspan="2"><p>C.</p>
<p>Tubercu- losis/</p>
<p>100,000</p></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="21"></td>
</tr>
<tr class="even">
<td colspan="21"><h3
id="treatment-needs-by-age-sex-and-raceethnicity">Treatment Needs by
Age, Sex, and Race/Ethnicity</h3></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>State:</strong></td>
<td colspan="16"></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="19"><strong><span class="smallcaps">Sex and
Race/Ethnicity</span></strong></td>
</tr>
<tr class="odd">
<td rowspan="2"><strong><span class="smallcaps">Age</span></strong></td>
<td rowspan="2"><strong><span class="smallcaps">A.
TOTAL</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">B.
WHITE</span></strong></td>
<td colspan="3"><strong><span class="smallcaps">C.
BLACK</span></strong></td>
<td colspan="2"><p><strong><span class="smallcaps">D. NATIVE HAWAIIAN
/OTHER</span></strong></p>
<p><strong><span class="smallcaps">PACIFIC
ISLANDER</span></strong></p></td>
<td colspan="2"><strong><span class="smallcaps">E.
ASIAN</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">F. AMERICAN INDIAN /
ALASKA NATIVE</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">G. MORE THAN ONE RACE
REPORTED</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">H.
UNKNOWN</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">I. NOT HISPANIC OR
LATINO</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">J. HISPANIC OR
LATINO</span></strong></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td colspan="2"><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
<td><strong><span class="smallcaps">M</span></strong></td>
<td><strong><span class="smallcaps">F</span></strong></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">1. 11 and under</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">2. 12 - 14</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">3. 15 - 17</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">4. 18 - 24</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">5. 25 – 44</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">6. 45 - 64</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong><span class="smallcaps">7. 65 and over</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong><span class="smallcaps">8. Total</span></strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

+-----------------+----------+--------+---------+------+-------+-----+
| ##### In        |          |        |         |      |       |     |
| tended Use Plan |          |        |         |      |       |     |
|                 |          |        |         |      |       |     |
| (Include ONLY   |          |        |         |      |       |     |
| funds to be     |          |        |         |      |       |     |
| spent by the    |          |        |         |      |       |     |
| agency          |          |        |         |      |       |     |
| administering   |          |        |         |      |       |     |
| the block       |          |        |         |      |       |     |
| grant.          |          |        |         |      |       |     |
| Estimated data  |          |        |         |      |       |     |
| are acceptable  |          |        |         |      |       |     |
| on this form.)  |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| State:          | ####     |        |         |      |       |     |
|                 |  Source  |        |         |      |       |     |
|                 | of Funds |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
|                 | (24      |        |         |      |       |     |
|                 | Month    |        |         |      |       |     |
|                 | Pro      |        |         |      |       |     |
|                 | jection) |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| **[Activity     | A. FY    | B.     | > C.    | D.   | E.    | F.  |
| ]{.smallcaps}** | 2005     | Me     | > Other | S    | Local | Ot  |
|                 |          | dicaid | >       | tate | funds | her |
| (See            | SAPT     |        | Federal | f    |       |     |
| instructions    |          | (Fe    | > Funds | unds | (excl |     |
|                 | Block    | deral, | >       |      | uding |     |
| for using Row   | Grant    | State, |  (e.g., |      | local |     |
| 1.)             |          | and    | > Me    |      |       |     |
|                 |          |        | dicare, |      | Medi  |     |
|                 |          | local) | > other |      | caid) |     |
|                 |          |        | >       |      |       |     |
|                 |          |        |  public |      |       |     |
|                 |          |        | > w     |      |       |     |
|                 |          |        | elfare) |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| 1.  Substance   |          |        |         |      |       |     |
|     Abuse       |          |        |         |      |       |     |
|     Treatment   |          |        |         |      |       |     |
|     and         |          |        |         |      |       |     |
|                 |          |        |         |      |       |     |
|  Rehabilitation |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| 2\. Primary     |          |        |         |      |       |     |
| Prevention      |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| 3               |          |        |         |      |       |     |
| .  Tuberculosis |          |        |         |      |       |     |
|     Services    |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| 4.  HIV Early   |          |        |         |      |       |     |
|                 |          |        |         |      |       |     |
|    Intervention |          |        |         |      |       |     |
|     Services    |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| 5\.             |          |        |         |      |       |     |
| Administration  |          |        |         |      |       |     |
|                 |          |        |         |      |       |     |
| (excluding      |          |        |         |      |       |     |
| program /       |          |        |         |      |       |     |
| provider level) |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+
| 6\. Column      |          |        |         |      |       |     |
| total           |          |        |         |      |       |     |
+-----------------+----------+--------+---------+------+-------+-----+

<table style="width:100%;">
<colgroup>
<col style="width: 10%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><h4 id="state">STATE: </h4></td>
<td colspan="14"><h4 id="section-72"></h4></td>
</tr>
<tr class="even">
<td colspan="17"><h4 id="treatment-capacity-matrix">Treatment Capacity
Matrix</h4>
<p>(Estimated data are acceptable on this form.)</p></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4"><strong>Primary Diagnosis of Alcohol
Problems</strong></td>
<td colspan="4"><strong>Primary Diagnosis of Drug Problems</strong></td>
<td colspan="4"><strong>Substance Abuse Problems (no primary
diagnosis)</strong></td>
<td colspan="3"><strong>State-validated Count</strong></td>
</tr>
<tr class="even">
<td rowspan="2">TYPE OF CARE</td>
<td rowspan="2"><p>A. Number of State</p>
<p>Approved Facilities (Service Delivery Units)</p></td>
<td colspan="2" rowspan="2"><p>B. Number of Services Provided</p>
<p>(Total Admissions)</p></td>
<td rowspan="2">C. Number of Persons Served</td>
<td rowspan="2"><p>D. Cost per Person</p>
<p>(Minimum – Maximum)</p></td>
<td rowspan="2"><p>E. Number of Services Provided</p>
<p>(Total Admissions)</p></td>
<td rowspan="2">F. Number of Persons Served</td>
<td colspan="2" rowspan="2"><p>G. Cost per Person</p>
<p>(Minimum – Maximum)</p></td>
<td rowspan="2"><p>H. Number of Services Provided</p>
<p>(Total Admissions)</p></td>
<td rowspan="2">I. Number of Persons Served</td>
<td colspan="2" rowspan="2"><p>J. Cost per Person</p>
<p>(Minimum – Maximum)</p></td>
<td colspan="3">K. (Check one box)</td>
</tr>
<tr class="odd">
<td>Yes</td>
<td colspan="2">No</td>
</tr>
<tr class="even">
<td colspan="16"><strong>DETOXIFICATION (24-HOUR CARE)</strong></td>
<td></td>
</tr>
<tr class="odd">
<td>1. Hospital Inpatient</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>2. Free-Standing Residential</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="17"><h2 id="rehabilitation-residential-2">REHABILITATION/
RESIDENTIAL</h2></td>
</tr>
<tr class="even">
<td>3. Hospital Inpatient</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>4. Short-term (up to 30 days)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>5. Long-term (over 30 days)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="17"><h2 id="ambulatory-outpatient-1">AMBULATORY
(Outpatient)</h2></td>
</tr>
<tr class="even">
<td>6. Outpatient Methadone</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>7. Outpatient Non-Methadone</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>8. Intensive Outpatient</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>9. Detoxification</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td></td>
<td></td>
<td colspan="2">$</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td><strong>TOTAL</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
</tbody>
</table>

**APPENDIX A**

**STATE PROJECT OFFICERS' DIRECTORY FOR**

**CENTER FOR SUBSTANCE ABUSE TREATMENT**

**CENTER FOR SUBSTANCE ABUSE PREVENTION**

**SYNAR PROJECT OFFICER STATE ASSIGNMENTS**

**LIST OF DESIGNATED HIV STATES**

+--------------------+---------+--------+--------+-------------------+
| Substance Abuse    |         |        |        |                   |
| and Mental Health  |         |        |        |                   |
| Services           |         |        |        |                   |
| Administration     |         |        |        |                   |
|                    |         |        |        |                   |
| Center for         |         |        |        |                   |
| Substance Abuse    |         |        |        |                   |
| Treatment          |         |        |        |                   |
|                    |         |        |        |                   |
| Division of State  |         |        |        |                   |
| and Community      |         |        |        |                   |
| Assistance         |         |        |        |                   |
|                    |         |        |        |                   |
| Performance        |         |        |        |                   |
| Partnership Grant  |         |        |        |                   |
| Branch             |         |        |        |                   |
|                    |         |        |        |                   |
| Telephone: (240)   |         |        |        |                   |
| 276-2890           |         |        |        |                   |
|                    |         |        |        |                   |
| Substance Abuse    |         |        |        |                   |
| Prevention and     |         |        |        |                   |
| Treatment Block    |         |        |        |                   |
| Grant Program      |         |        |        |                   |
|                    |         |        |        |                   |
| State Project      |         |        |        |                   |
| Officer Directory  |         |        |        |                   |
+====================+=========+========+========+===================+
| State              | Project | Tel    | Fac    | E-Mail            |
|                    | O       | ephone | simile |                   |
|                    | fficers |        |        |                   |
+--------------------+---------+--------+--------+-------------------+
| Alabama            | Willard | \      | \      | <Willard.Saunder  |
|                    | S       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | aunders | 27     | 27     |                   |
|                    |         | 6-2906 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Alaska             | Claudia | \      | \      | <Claudia.Richard  |
|                    | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Arizona            | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Arkansas           | E       | \      | \      | <Eleanore.McCo    |
|                    | leanore | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    | McCoy   | 27     | 27     |                   |
|                    |         | 6-2899 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| California         | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Colorado           | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Connecticut        | Ruby    | \      | \      | <Ruby.Nevill      |
|                    | Neville | (240\) | (240\) | e@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2902 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Delaware           | Lonn    | \      | \      | <Lonn.Aussicke    |
|                    | Au      | (240\) | (240\) | r@samhsa.hhs.gov> |
|                    | ssicker | 27     | 27     |                   |
|                    |         | 6-2889 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| District of        | Claudia | \      | \      | <Claudia.Richard  |
| Columbia           | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Florida            | Willard | \      | \      | <Willard.Saunder  |
|                    | S       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | aunders | 27     | 27     |                   |
|                    |         | 6-2906 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Georgia            | Willard | \      | \      | <Willard.Saunder  |
|                    | S       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | aunders | 27     | 27     |                   |
|                    |         | 6-2906 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Hawaii             | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Idaho              | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Illinois           | Claudia | \      | \      | <Claudia.Richard  |
|                    | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Indiana            | Carol   | \      | \      | <Carol.Cole       |
|                    | Coley   | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2892 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Iowa               | V       | \      | \      | <Veronica.Munso   |
|                    | eronica | (240\) | (240\) | n@samhsa.hhs.gov> |
|                    | Munson  | 27     | 27     |                   |
|                    |         | 6-2901 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Kansas             | V       | \      | \      | <Veronica.Munso   |
|                    | eronica | (240\) | (240\) | n@samhsa.hhs.gov> |
|                    | Munson  | 27     | 27     |                   |
|                    |         | 6-2901 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Kentucky           | Lonn    | \      | \      | <Lonn.Aussicke    |
|                    | Au      | (240\) | (240\) | r@samhsa.hhs.gov> |
|                    | ssicker | 27     | 27     |                   |
|                    |         | 6-2889 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Louisiana          | E       | \      | \      | <Eleanore.McCo    |
|                    | leanore | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    | McCoy   | 27     | 27     |                   |
|                    |         | 6-2899 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Maine              | Ruby    | \      | \      | <Ruby.Nevill      |
|                    | Neville | (240\) | (240\) | e@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2902 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Maryland           | Lonn    | \      | \      | <Lonn.Aussicke    |
|                    | Au      | (240\) | (240\) | r@samhsa.hhs.gov> |
|                    | ssicker | 27     | 27     |                   |
|                    |         | 6-2889 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Massachusetts      | Ruby    | \      | \      | <Ruby.Nevill      |
|                    | Neville | (240\) | (240\) | e@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2902 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Michigan           | Carol   | \      | \      | <Carol.Cole       |
|                    | Coley   | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2892 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Minnesota          | Carol   | \      | \      | <Carol.Cole       |
|                    | Coley   | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2892 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Red Lake Band of   | Carol   | \      | \      | <Carol.Cole       |
| the Chippewa (MN)  | Coley   | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2892 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Mississippi        | E       | \      | \      | <Eleanore.McCo    |
|                    | leanore | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    | McCoy   | 27     | 27     |                   |
|                    |         | 6-2899 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Missouri           | V       | \      | \      | <Veronica.Munso   |
|                    | eronica | (240\) | (240\) | n@samhsa.hhs.gov> |
|                    | Munson  | 27     | 27     |                   |
|                    |         | 6-2901 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Montana            | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Nebraska           | V       | \      | \      | <Veronica.Munso   |
|                    | eronica | (240\) | (240\) | n@samhsa.hhs.gov> |
|                    | Munson  | 27     | 27     |                   |
|                    |         | 6-2901 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Nevada             | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| New Hampshire      | Ruby    | \      | \      | <Ruby.Nevill      |
|                    | Neville | (240\) | (240\) | e@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2902 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| New Jersey         | Claudia | \      | \      | <Claudia.Richard  |
|                    | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| New Mexico         | E       | \      | \      | <Eleanore.McCo    |
|                    | leanore | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    | McCoy   | 27     | 27     |                   |
|                    |         | 6-2899 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| New York           | Claudia | \      | \      | <Claudia.Richard  |
|                    | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| North Carolina     | Willard | \      | \      | <Willard.Saunder  |
|                    | S       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | aunders | 27     | 27     |                   |
|                    |         | 6-2906 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| North Dakota       | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Ohio               | Carol   | \      | \      | <Carol.Cole       |
|                    | Coley   | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2892 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Oklahoma           | E       | \      | \      | <Eleanore.McCo    |
|                    | leanore | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    | McCoy   | 27     | 27     |                   |
|                    |         | 6-2899 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Oregon             | V       | \      | \      | <Veronica.Munso   |
|                    | eronica | (240\) | (240\) | n@samhsa.hhs.gov> |
|                    | Munson  | 27     | 27     |                   |
|                    |         | 6-2901 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Pennsylvania       | Lonn    | \      | \      | <Lonn.Aussicke    |
|                    | Au      | (240\) | (240\) | r@samhsa.hhs.gov> |
|                    | ssicker | 27     | 27     |                   |
|                    |         | 6-2889 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Rhode Island       | Ruby    | \      | \      | <Ruby.Nevill      |
|                    | Neville | (240\) | (240\) | e@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2902 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| South Carolina     | Willard | \      | \      | <Willard.Saunder  |
|                    | S       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | aunders | 27     | 27     |                   |
|                    |         | 6-2906 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| South Dakota       | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Tennessee          | Willard | \      | \      | <Willard.Saunder  |
|                    | S       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | aunders | 27     | 27     |                   |
|                    |         | 6-2906 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Texas              | E       | \      | \      | <Eleanore.McCo    |
|                    | leanore | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    | McCoy   | 27     | 27     |                   |
|                    |         | 6-2899 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Utah               | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Vermont            | Ruby    | \      | \      | <Ruby.Nevill      |
|                    | Neville | (240\) | (240\) | e@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2902 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Virginia           | Lonn    | \      | \      | <Lonn.Aussicke    |
|                    | Au      | (240\) | (240\) | r@samhsa.hhs.gov> |
|                    | ssicker | 27     | 27     |                   |
|                    |         | 6-2889 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Washington         | V       | \      | \      | <Veronica.Munso   |
|                    | eronica | (301\) | (240\) | n@samhsa.hhs.gov> |
|                    | Munson  | 44     | 27     |                   |
|                    |         | 3-9712 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| West Virginia      | Lonn    | \      | \      | <Lonn.Aussicke    |
|                    | Au      | (240\) | (240\) | r@samhsa.hhs.gov> |
|                    | ssicker | 27     | 27     |                   |
|                    |         | 6-2889 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Wisconsin          | Carol   | \      | \      | <Carol.Cole       |
|                    | Coley   | (240\) | (240\) | y@samhsa.hhs.gov> |
|                    |         | 27     | 27     |                   |
|                    |         | 6-2892 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Wyoming            | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| American Samoa     | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Guam               | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Marshall Islands   | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Micronesia         | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Palau              | John    | \      | \      | <John.Campbel     |
|                    | C       | (240\) | (240\) | l@samhsa.hhs.gov> |
|                    | ampbell | 27     | 27     |                   |
|                    |         | 6-2891 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| Puerto Rico        | Claudia | \      | \      | <Claudia.Richard  |
|                    | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+
| U.S. Virgin        | Claudia | \      | \      | <Claudia.Richard  |
| Islands            | R       | (240\) | (240\) | s@samhsa.hhs.gov> |
|                    | ichards | 27     | 27     |                   |
|                    |         | 6-2904 | 6-2900 |                   |
+--------------------+---------+--------+--------+-------------------+

+-----------------+-----------+--------+---------+-------------------+
| Substance Abuse |           |        |         |                   |
| and Mental      |           |        |         |                   |
| Health Services |           |        |         |                   |
| Administration  |           |        |         |                   |
|                 |           |        |         |                   |
| Center for      |           |        |         |                   |
| Substance Abuse |           |        |         |                   |
| Prevention      |           |        |         |                   |
|                 |           |        |         |                   |
| Division of     |           |        |         |                   |
| State and       |           |        |         |                   |
| Community       |           |        |         |                   |
| Systems         |           |        |         |                   |
| Development     |           |        |         |                   |
|                 |           |        |         |                   |
| State and       |           |        |         |                   |
| Community       |           |        |         |                   |
| Systems         |           |        |         |                   |
| Application     |           |        |         |                   |
| Branch          |           |        |         |                   |
|                 |           |        |         |                   |
| Telephone:      |           |        |         |                   |
| (240) 276-2570  |           |        |         |                   |
|                 |           |        |         |                   |
| Substance Abuse |           |        |         |                   |
| Prevention and  |           |        |         |                   |
| Treatment Block |           |        |         |                   |
| Grant Program   |           |        |         |                   |
|                 |           |        |         |                   |
| State Project   |           |        |         |                   |
| Officer         |           |        |         |                   |
| Directory       |           |        |         |                   |
+=================+===========+========+=========+===================+
| State           | Project   | Tel    | Fa      | E-Mail            |
|                 | Officers  | ephone | csimile |                   |
+-----------------+-----------+--------+---------+-------------------+
| Alabama         | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Alaska          | Russell   | \      | \(240\) | <Russell.Pierc    |
|                 | Pierce    | (240\) | 2       | e@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2587 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Arizona         | Mary Lou  | \      | \(240\) | <Marylou.De       |
|                 | Dent      | (240\) | 2       | nt@samhsa.hhsgov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2572 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Arkansas        | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| California      | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
|                 | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
|                 | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Colorado        | Mary Lou  | \      | \(240\) | <Marylou.De       |
|                 | Dent      | (240\) | 2       | nt@samhsa.hhsgov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2572 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Connecticut     | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Delaware        | Sheri     | \      | \(240\) | <Sheri.Rucke      |
|                 | Rucker    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2584 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| District of     | Sheri     | \      | \(240\) | <Sheri.Rucke      |
| Columbia        | Rucker    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2584 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Florida         | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Georgia         | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Hawaii          | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Idaho           | Mary Lou  | \      | \(240\) | <Marylou.De       |
|                 | Dent      | (240\) | 2       | nt@samhsa.hhsgov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2572 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Illinois        | Clarese   | \      | \(240\) | <Clarese.Holde    |
|                 | Holden    | (240\) | 2       | n@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2579 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Indiana         | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Iowa            | Karen     | \      | \(240\) | <Karen.Sale       |
|                 | Salem     | (240\) | 2       | m@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2585 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Kansas          | Mary Lou  | \      | \(240\) | <Marylou.De       |
|                 | Dent      | (240\) | 2       | nt@samhsa.hhsgov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2572 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Kentucky        | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Louisiana       | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Maine           | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Maryland        | Sheri     | \      | \(240\) | <Sheri.Rucke      |
|                 | Rucker    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2584 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Massachusetts   | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Michigan        | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Minnesota       | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
|                 | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
|                 | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Red Lake Band   | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
| of the Chippewa | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
| (MN)            | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Mississippi     | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Missouri        | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Montana         | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
|                 | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
|                 | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Nebraska        | Sheri     | \      | \(240\) | <Sheri.Rucke      |
|                 | Rucker    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2584 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Nevada          | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
|                 | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
|                 | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| New Hampshire   | Russell   | \      | \(240\) | <Russell.Pierc    |
|                 | Pierce    | (240\) | 2       | e@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2587 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| New Jersey      | Russell   | \      | \(240\) | <Russell.Pierc    |
|                 | Pierce    | (240\) | 2       | e@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2587 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| New Mexico      | Sheri     | \      | \(240\) | <Sheri.Rucke      |
|                 | Rucker    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2584 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| New York        | Clarese   | \      | \(240\) | <Clarese.Holde    |
|                 | Holden    | (240\) | 2       | n@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2579 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| North Carolina  | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| North Dakota    | Karen     | \      | \(240\) | <Karen.Sale       |
|                 | Salem     | (240\) | 2       | m@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2585 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Ohio            | Karen     | \      | \(240\) | <Karen.Sale       |
|                 | Salem     | (240\) | 2       | m@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2585 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Oklahoma        | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Oregon          | Karen     | \      | \(240\) | <Karen.Sale       |
|                 | Salem     | (240\) | 2       | m@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2585 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Pennsylvania    | Clarese   | \      | \(240\) | <Clarese.Holde    |
|                 | Holden    | (240\) | 2       | n@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2579 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Rhode Island    | Donna     | \      | \(240\) | <Donna.Simm       |
|                 | Simms     | (240\) | 2       | s@samhsa.hhs.gov> |
|                 | d'Almeida | 27     | 76-2580 |                   |
|                 |           | 6-2586 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| South Carolina  | Mary Lou  | \      | \(240\) | <Marylou.De       |
|                 | Dent      | (240\) | 2       | nt@samhsa.hhsgov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2572 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| South Dakota    | Karen     | \      | \(240\) | <Karen.Sale       |
|                 | Salem     | (240\) | 2       | m@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2585 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Tennessee       | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Texas           | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
|                 | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
|                 | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Utah            | Mary Lou  | \      | \(240\) | <Marylou.De       |
|                 | Dent      | (240\) | 2       | nt@samhsa.hhsgov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2572 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Vermont         | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Virginia        | Clarese   | \      | \(240\) | <Clarese.Holde    |
|                 | Holden    | (240\) | 2       | n@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2579 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Washington      | Sheri     | \      | \(240\) | <Sheri.Rucke      |
|                 | Rucker    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2584 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| West Virginia   | Karen     | \      | \(240\) | <Karen.Sale       |
|                 | Salem     | (240\) | 2       | m@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2585 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Wisconsin       | Jon       | \      | \(240\) | <Jon.Dunba        |
|                 | Dunbar    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 | Cooper    | 27     | 76-2580 |                   |
|                 |           | 6-2573 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Wyoming         | Mary      | \      | \(301\) | <Maryjoyce.Prude  |
|                 | Joyce     | (240\) | 4       | n@samhsa.hhs.gov> |
|                 | Pruden    | 27     | 43-0526 |                   |
|                 |           | 6-2582 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| American Samoa  | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Guam            | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Marshall        | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
| Islands         | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Micronesia      | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Palau           | Sherrye   | \      | \(240\) | <Sherrye.Fowle    |
|                 | Fowler    | (240\) | 2       | r@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2576 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| Puerto Rico     | Clarese   | \      | \(240\) | <Clarese.Holde    |
|                 | Holden    | (240\) | 2       | n@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2579 |         |                   |
+-----------------+-----------+--------+---------+-------------------+
| US. Virgin      | Clarese   | \      | \(240\) | <Clarese.Holde    |
| Islands         | Holden    | (240\) | 2       | n@samhsa.hhs.gov> |
|                 |           | 27     | 76-2580 |                   |
|                 |           | 6-2579 |         |                   |
+-----------------+-----------+--------+---------+-------------------+

+----------------+-----------+---------+---------+--------------------+
| Substance      |           |         |         |                    |
| Abuse and      |           |         |         |                    |
| Mental Health  |           |         |         |                    |
| Services       |           |         |         |                    |
| Administration |           |         |         |                    |
|                |           |         |         |                    |
| Center for     |           |         |         |                    |
| Substance      |           |         |         |                    |
| Abuse          |           |         |         |                    |
| Prevention     |           |         |         |                    |
| (CSAP)         |           |         |         |                    |
|                |           |         |         |                    |
| Division of    |           |         |         |                    |
| State and      |           |         |         |                    |
| Community      |           |         |         |                    |
| Systems        |           |         |         |                    |
| Development    |           |         |         |                    |
| (DSCSD)        |           |         |         |                    |
|                |           |         |         |                    |
| Systems        |           |         |         |                    |
| Application    |           |         |         |                    |
| Branch         |           |         |         |                    |
|                |           |         |         |                    |
| Telephone:     |           |         |         |                    |
| (240) 276-2570 |           |         |         |                    |
|                |           |         |         |                    |
| Substance      |           |         |         |                    |
| Abuse          |           |         |         |                    |
| Prevention and |           |         |         |                    |
| Treatment      |           |         |         |                    |
| Block Grant    |           |         |         |                    |
| Program        |           |         |         |                    |
|                |           |         |         |                    |
| Synar Project  |           |         |         |                    |
| Officer State  |           |         |         |                    |
| Assignments    |           |         |         |                    |
+================+===========+=========+=========+====================+
| State          | Project   | Te      | Fa      | E-Mail             |
|                | Officers  | lephone | csimile |                    |
+----------------+-----------+---------+---------+--------------------+
| Alabama        | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Alaska         | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Arizona        | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
|                | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Arkansas       | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| California     | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Colorado       | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Connecticut    | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Delaware       | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| District of    | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
| Columbia       | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Florida        | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
|                | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Georgia        | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Hawaii         | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Idaho          | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
|                | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Illinois       | Julia     | \(240\) | \(240\) | <Julia.Spenc       |
|                | Spencer   | 2       | 2       | er@samhsa.hhs.gov> |
|                |           | 76-2564 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Indiana        | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Iowa           | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Kansas         | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Kentucky       | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Louisiana      | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Maine          | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Maryland       | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Massachusetts  | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Michigan       | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Minnesota      | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Mississippi    | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Missouri       | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Montana        | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
|                | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Nebraska       | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Nevada         | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
|                | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| New Hampshire  | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| New Jersey     | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| New Mexico     | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| New York       | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| North Carolina | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| North Dakota   | Steve     | \(240\) | \(240\) | <Steve.Mcelra      |
|                | McElravy  | 2       | 2       | vy@samhsa.hhs.gov> |
|                |           | 76-2563 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Ohio           | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Oklahoma       | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Oregon         | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Pennsylvania   | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Rhode Island   | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| South Carolina | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| South Dakota   | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Tennessee      | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Texas          | Julia     | \(240\) | \(240\) | <Julia.Spenc       |
|                | Spencer   | 2       | 2       | er@samhsa.hhs.gov> |
|                |           | 76-2564 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Utah           | Susan     | \(240\) | \(240\) | <Susan.Marsigl     |
|                | Marsiglia | 2       | 2       | ia@samhsa.hhs.gov> |
|                |           | 76-2568 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Vermont        | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Virginia       | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Washington     | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| West Virginia  | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Wisconsin      | Julia     | \(240\) | \(240\) | <Julia.Spenc       |
|                | Spencer   | 2       | 2       | er@samhsa.hhs.gov> |
|                |           | 76-2564 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Wyoming        | Grant     | \(240\) | \(240\) | <Grant.Hil         |
|                | Hills     | 2       | 2       | ls@samhsa.hhs.gov> |
|                |           | 76-2562 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| American Samoa | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Guam           | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Marshall       | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
| Islands        | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Micronesia     | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Palau          | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
|                | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| Puerto Rico    | Alejandro | \(240\) | \(240\) | <Alejandro.Ari     |
|                | Arias     | 2       | 2       | as@samhsa.hhs.gov> |
|                |           | 76-2569 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+
| U.S. Virgin    | Carolyn   | \(240\) | \(240\) | <Carolyn.Stephens  |
| Islands        | S         | 2       | 2       | on@samhsa.hhs.gov> |
|                | tephenson | 76-2566 | 76-2580 |                    |
+----------------+-----------+---------+---------+--------------------+

**HIV DESIGNATED STATES**

**FOR FY 2005**

  -------------------------------------------------------------------------------------------------
  Designated                                                                         
  States[^3] for FY                                                                  
  2005 SAPT Block                                                                    
  Grant Uniform                                                                      
  Application                                                                        
  ------------------- ---------- ----------------- --------------- ----------------- --------------
  State[^4]           Rate[^5]   FY 2005           FY 1991         \%                HIV Set-Aside
                                 SAPTBG[^6]        ADMSBG[^7]      Change1991-2005   

  Number range        9.6        \$24,276,034      \$12,409,695                      
  CHAPTERAlabama                                                                     

  Alaska              5.1        \$5,105,706       \$2,449,664                       

  **Arizona**         11.5       \$34,056,247      \$13,840,593    146%              \$1,702,812

  Arkansas            8.9        \$14,005,800      \$4,807,518                       

  **California**      12.4       \$255,274,603     \$130,425,411   95.7%             \$12,763,730

  Colorado            7.4        \$25,040,971      \$13,956,718                      

  **Connecticut**     17.9       \$17,109,157      \$13,882,960    23.2%             \$855,458

  **Delaware**        23.9       \$6,870,881       \$3,148,031     118%              \$343,544

  **District of       162.4      \$6,870,881       \$4,790,552     43.4%             \$343,544
  Columbia**                                                                         

  **Florida**         30.3       \$101,190,221     \$47,792,540    112%              \$5,059,511

  **Georgia**         17.2       \$53,535,677      \$17,701,223    202%              \$2,676,784

  **Hawaii**          10.3       \$7,299,294       \$4,590,998     59%               \$364,965

  Idaho               2.3        \$7,496,616       \$2,173,396                       

  **Illinois**        16.7       \$71,994,162      \$48,009,708    50%               \$3,599,708

  Indiana             8.0        \$33,903,183      \$14,663,226                      

  Number range        3.2        \$14,401,259      \$8,582,512                       
  CHAPTERIowa                                                                        

  Kansas              2.6        \$12,576,367      \$5,948,610                       

  Kentucky            7.5        \$21,288,391      \$11,290,513                      

  **Louisiana**       26.0       \$26,312,516      \$17,671,416    49%               \$1,315,626

  Maine               2.2        \$6,870,881       \$2,860,348                       

  **Maryland**        34.0       \$33,831,224      \$22,705,061    49%               \$1,691,561

  **Massachusetts**   12.6       \$35,120,622      \$26,059,220    34.7%             \$1,756,031

  Michigan            7.9        \$58,933,358      \$40,890,802                      

  Minnesota           3.2        \$23,014,406      \$14,843,236                      

  Red Lake-Chippewa              \$567,221         \$390,000                         
  (MN)                                                                               

  **Mississippi**     15.1       \$14,948,256      \$4,749,463     215%              \$747,413

  Missouri            6.9        \$27,543,613      \$16,984,801                      

  Montana             1.9        \$6,870,881       \$1,940,827                       

  Nebraska            4.0        \$8,404,456       \$4,662,147                       

  **Nevada**          14.4       \$13,919,177      \$4,317,190     222%              \$695,959

  New Hampshire       3.2        \$6,870,881       \$1,980,819                       

  **New Jersey**      16.7       \$47,845,372      \$35,398,346    35%               \$2,392,269

  New Mexico          4.7        \$9,407,916       \$4,209,623                       

  **Number range      34.8       \$117,851,388     \$93,451,518    26%               \$5,892,569
  CHAPTERNew York**                                                                  

  **North Carolina**  12.8       \$39,995,231      \$16,092,236    148%              \$1,999,762

  North Dakota        0.5        \$5,664,454       \$1,708,762                       

  Ohio                6.8        \$67,852,167      \$38,367,574                      

  Oklahoma            5.8        \$18,586,062      \$8,250,691                       

  Oregon              8.5        \$17,055,914      \$10,323,828                      

  **Pennsylvania**    14.7       \$61,002,618      \$46,860,078    30%               \$3,050,131

  **Rhode Island**    10.0       \$6,870,881       \$4,952,253     38.7%             \$343,544

  **South Carolina**  20.3       \$21,867,330      \$59,718,124    125%              \$1,093,367

  South Dakota        1.4        \$5,238,039       \$1,893,408                       

  **Tennessee**       13.7       \$30,649,211      \$14,221,946    116%              \$1,532,461

  **Texas**           14.4       \$144,623,000     \$62,406,552    132%              \$7,231,150

  Utah                4.1        \$17,858,164      \$7,325,996                       

  Vermont             1.9        \$5,600,578       \$1,907,282                       

  **Virginia**        13.1       \$45,613,929      \$21,505,683    112%              \$2,280,696

  Washington          7.9        \$35,603,111      \$17,928,552                      

  West Virginia       4.6        \$8,901,574       \$3,501,025                       

  Number range        3.4        \$27,282,819      \$18,849,237                      
  CHAPTERWisconsin                                                                   

  Wyoming             2.4        \$3,639,200       \$972,873                         

  **Subtotal,                    1,714,513,091                                       \$59,732,595
  States**                                                                           

  American Samoa                 \$331,958                                           

  Guam                           \$896,979                                           

  Marshall Islands               \$294,580                                           

  Federated States of            \$620,031                                           
  Micronesia                                                                         

  Commonwealth of the            \$401,084                                           
  Northern Mariana                                                                   
  Islands                                                                            

  Palau                          \$114,146                                           

  **Puerto Rico**     29.5       \$22,726,536      \$12,608,307    80.2%             \$1,136,327

  **Virgin Islands,   47.0       \$648,104         \$520,633       24.4%             \$32,405
  U.S.**                                                                             

  **Subtotal,                    \$26,109,349                                        \$1,168,732
  Territories**                                                                      

  **SAMHSA                       \$91,611,750                                        
  Set-Aside**                                                                        

  **Total, SAPTBG**              \$1,832,235,000                                     \$60,901,327
  -------------------------------------------------------------------------------------------------

c:\\word\\saptbg\\bgas\\fy2005\\fy 2005 uniform application final
08-31-04.doc

[^1]: ^?^The term State is used to refer to all the States and
    territories eligible to receive Substance Abuse Prevention and
    Treatment Block Grant funds (See 42 U.S.C. 300x-64 and 45 C.F.R.
    96.121).

[^2]: ^?^Table 14, **[AIDS cases and rates (per 100,000 population), by
    area of residence and age category, reported through December 2002,
    United States]{.underline}**, HIV/AIDS Surveillance Report, 2002,
    14, U.S. Department of Health and Human Services, Centers for
    Disease Control and Prevention, National Center for HIV, STD, and TB
    Prevention, Division of HIV/AIDS, Prevention, Surveillance, and
    Epidemiology. Single copies of the report are available through the
    CDC National Prevention Information Network, 1-800-458-5231 or
    301-562-1098 or <http://www.cdc.gov/hiv/stats/hasrlink.htm>

[^3]: The term "designated State" means any State whose rate of cases of
    acquired immune deficiency syndrome (AIDS) is 10 or more such cases
    per 100,000 individuals (as indicated by the number of such cases
    reported to and confirmed by the Centers for Disease Control and
    Prevention (CDC) for the most recent calendar year for which the
    data are available ([See]{.underline} 45 CFR 96.128(b).

[^4]: Total of 25 "designated States" (including District of Columbia,
    Puerto Rico, and the Virgin Islands)

[^5]: The most recent data published prior to October 1, 2003 by the CDC
    is Table 14, **[AIDS cases and rates (per 100,000 population), by
    area of residence and age category, reported through December 2002,
    United States]{.underline}**, HIV/AIDS Surveillance Report, 2002,
    14, U.S. Department of Health and Human Services, Centers for
    Disease Control and Prevention, National Center for HIV, STD, and TB
    Prevention, Division of HIV/AIDS, Prevention, Surveillance, and
    Epidemiology. Single copies of the report are available through the
    CDC National Prevention Information Network, 1-800-458-5231 or
    301-562-1098 or <http://www.cdc.gov/hiv/stats/hasrlink.htm>

[^6]: Source: FY 2005 Estimate.

[^7]: FY 1991 is the base year to determine amount of set-aside (Source:
    Section 1924 (b)(4) of the Public Health Service Act).