Department of Health and Human Services

**Substance Abuse and Mental Health Services Administration**

**Strengthening Treatment Access and Retention -- State Implementation
Cooperative Agreements**

**(STAR-SI)**

(Initial Announcement)

**TI-06-006**

**Catalogue of Federal Domestic Assistance (CFDA) No**.: 93.243

**Key Dates:**

+----------------------+-----------------------------------------------+
| **Application        | **Applications are due by March 24, 2006.**   |
| Deadline**           |                                               |
+----------------------+-----------------------------------------------+
| **Intergovernmental  | **Letters from State Single Point of Contact  |
| Review**             | (SPOC) are due no later than 60 days after    |
|                      | application deadline.**                       |
| **(E.O. 12372)**     |                                               |
+----------------------+-----------------------------------------------+

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

H. Westley Clark, M.D., J.D., M.P.H. Charles G. Curie, M.A., A.C.S.W.

Director, Center for Substance Abuse Treatment Administrator

Substance Abuse and Mental Health Substance Abuse and Mental Health

Services Administration Services Administration

**Table of Contents**

[I. FUNDING OPPORTUNITY DESCRIPTION
2](#i.-funding-opportunity-description)

[1. INTRODUCTION 2](#introduction)

[2. EXPECTATIONS 2](#expectations)

[II. AWARD INFORMATION 6](#ii.-award-information)

[1. AWARD AMOUNT 6](#award-amount)

[2. FUNDING MECHANISM 7](#funding-mechanism)

[III. ELIGIBILITY INFORMATION 7](#iii.-eligibility-information)

[1. ELIGIBLE APPLICANTS 8](#eligible-applicants)

[2. COST SHARING 8](#cost-sharing)

[IV. APPLICATION AND SUBMISSION INFORMATION
8](#iv.-application-and-submission-information)

[1. ADDRESS TO REQUEST APPLICATION PACKAGE
8](#address-to-request-application-package)

[2. CONTENT AND FORM OF APPLICATION SUBMISSION
9](#content-and-form-of-application-submission)

[3. SUBMISSION DATES AND TIMES 14](#submission-dates-and-times)

[4. INTERGOVERNMENTAL REVIEW (E.O. 12372) REQUIREMENTS
14](#intergovernmental-review-e.o.-12372-requirements)

[5. FUNDING LIMITATIONS/RESTRICTIONS
15](#funding-limitationsrestrictions)

[6. OTHER SUBMISSION REQUIREMENTS 16](#other-submission-requirements)

[V. APPLICATION REVIEW INFORMATION
17](#v.-application-review-information)

[1. EVALUATION CRITERIA 17](#evaluation-criteria)

[2. REVIEW AND SELECTION PROCESS 20](#review-and-selection-process)

[VI. AWARD ADMINISTRATION INFORMATION
20](#vi.-award-administration-information)

[1. AWARD NOTICES 21](#award-notices)

[2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS
21](#administrative-and-national-policy-requirements)

[3. REPORTING REQUIREMENTS 22](#reporting-requirements)

[VII. AGENCY CONTACTS 22](#vii.-agency-contacts)

[Appendix A -- Checklist for Formatting Requirements and Screenout
Criteria for SAMHSA Grant Applications
24](#appendix-a-checklist-for-formatting-requirements-and-screenout-criteria-for-samhsa-grant-applications)

[Appendix B - Glossary 26](#appendix-b---glossary)

[Appendix C --Resources 28](#appendix-c-resources)

[Appendix D -- Sample Budget and Justification
29](#appendix-d-sample-budget-and-justification)

[Appendix E - Examples of State Specific Access and Retention Measures
33](#appendix-e---examples-of-state-specific-access-and-retention-measures)

[Appendix F - CSAT Core GPRA Client Outcome Tool
34](#appendix-f---csat-core-gpra-client-outcome-tool)

# I. FUNDING OPPORTUNITY DESCRIPTION

## 1. INTRODUCTION

The Substance Abuse and Mental Health Services Administration's (SAMHSA)
Center for Substance Abuse Treatment (CSAT) announces the availability
of FY 2006 funds for the Strengthening Treatment Access and Retention --
State Implementation (STAR-SI) program. STAR-SI is an infrastructure
cooperative agreement program that promotes State-level implementation
of process improvement methods to improve access to and retention in
outpatient treatment. Outpatient treatment facilities account for 80
percent of all substance abuse treatment programs in the United States
and serve 89 percent of the 1.1 million clients in care on any day
([National Survey of Substance Abuse Treatment Services, SAMHSA,
2002)]{.underline}. Outpatient treatment providers face tremendous
challenges in their efforts to serve populations in need of treatment.
States are in a unique position to effect system change by working
together with outpatient substance abuse treatment providers to remove
systems barriers, streamline administrative procedures, provide
incentives and assist provider networks in their efforts to improve
access and retention performance outcomes.

Note: While the terms "State" and "State-level" implementation are used
throughout this document, federally recognized tribes and tribal
organizations are also eligible for this program (See Section III.
Eligibility Information).

STAR-SI grants are authorized under Section 509 of the Public Health
Service Act, as amended.

This announcement addresses Healthy People 2010 focus area 26 (Substance
Abuse).

## 2. EXPECTATIONS

## 2.1 Background

The STAR-SI program builds on the findings of the Network for the
Improvement of Addiction Treatment (NIATx), a joint initiative of
SAMHSA's CSAT and the Robert Wood Johnson Foundation (RWJF). Under this
initiative, 13 CSAT Strengthening Treatment Access and Retention (STAR)
and 27 RWJF Paths to Recovery grantees have substantially increased
client access and retention using process improvement methods. Examples
of organizational improvements that were successfully implemented by
STAR and Paths to Recovery grantees include: streamlining client intake,
assessment and appointment scheduling procedures; eliminating paperwork
duplication; extending clinic hours; contacting client no shows;
eliciting customer feedback; and using clinical protocols, e.g.,
motivational interviewing and motivational incentives to engage clients
during the initial phase of treatment. The NIATx initiative also
demonstrated that process improvement skills can be successfully
transferred to treatment organizations. Grantees participated in a
learning network that included semi-annual learning sessions, process
improvement coaching, web resources, information sharing, and
peer-to-peer learning opportunities.

Over the past decade, process improvement has been successfully used by
businesses and health care organizations to improve performance outcomes
(Kaynak, 2003; Pearson et al, 2005). Broadly defined, process
improvement is a method developed and tested within the field of
continuous quality improvement (CQI) that applies Plan-Do-Study-Act
(PDSA) cycles to improve organizational processes. PDSA cycles are used
by organizations to set improvement targets, pilot test changes and
analyze outcomes using demonstrated performance measurement tools
(Juran, 1988; Clemmer et al, 2005; Ragsdale & Mueller, 2005). The
improvement process implemented by NIATx is an adaptation of the Model
for Improvement (Langley et al, 1996) that uses a "rapid cycle" PDSA in
conjunction with tools designed to improve customer orientation and
involve key stakeholders in the organization, including the CEO and a
designated change leader (Gufstason and Hunt, 1995). Information on
process improvement, principles, toolkits, outcomes and applications by
NIATx members is available through the "*Resource Guide to Process
Improvement"* on the NIATx website at
[http://www.niatx.net](http://www.niatx.net/).

## 2.2 Program Requirements

STAR-SI program grantees will: (1) use process improvement methods to
improve both State and treatment agency level organizational processes
that impact client access to and retention in outpatient substance abuse
treatment services; (2) develop provider and payer capacity to implement
process improvement methods through the operation of peer-to-peer
learning networks; (3) partner with outpatient treatment providers,
including, when applicable, the State treatment provider association and
key fiscal intermediaries, in program design and implementation; and (4)
implement a performance management system to track progress and provide
feedback to participating treatment providers on performance outcomes.

**2.3 Required Activities**

STAR-SI cooperative agreement funds [must]{.underline} be used to carry
out each of the following [required]{.underline} activities:

-   Dedicate a minimum of 30 percent of a full time position, i.e., an
    [existing]{.underline} senior level manager/change leader, to
    oversee implementation of the program. The senior level
    manager/change leader should be an individual that currently reports
    directly to the Single State Substance Abuse Authority (SSA)
    Director and is in a position to engage key stakeholders, implement
    change processes at the State level to remove barriers or establish
    incentives related to the program aims, oversee the development of
    provider learning networks, and implement required data collection
    and performance tracking systems. STAR-SI grantees must assure that
    the identified individual will have direct access to the SSA
    Director and that the SSA Director will provide active leadership
    and support for the program, e.g., remove system barriers,
    personally engage in process improvement walkthroughs, etc.;

-   Dedicate a minimum of 50 percent of a full time position to a
    program coordinator position, i.e., a mid level program manager that
    reports directly to the senior level manager/change leader. This
    individual will be responsible for the day to day operation of STAR-
    SI, including coordination of project tasks among the management
    staff and stakeholders, management of the peer learning network, and
    oversight of performance measure tracking activities and program
    reporting. STAR-SI grantees must assure that the identified
    individual has demonstrated experience and skills to facilitate team
    building and communicate effectively with STAR-SI management staff
    and identified stakeholders;

-   Partner with outpatient treatment providers, including when
    applicable, the State treatment provider association and fiscal
    intermediaries, if applicable, in the implementation of the STAR-SI
    program, including appropriate representation and involvement of the
    program management team;

-   Use the process improvement (PI) methods developed under CSAT's STAR
    program and Network for the Improvement of Addiction Treatment
    (NIATx) ([www.niatx.net](http://www.niatx.net/)) to implement the
    following activities at both the State and treatment provider
    level: (1) setting access and retention performance targets; (2)
    implementing improvement activities related to these targets; (3)
    establishing performance management systems; and (4) monitoring
    performance outcomes to ensure sustainability and progress in
    spreading improvements to additional treatment providers throughout
    the State;

-   During the first year of the program, demonstrate access and
    retention improvements with a minimum of five community based
    outpatient treatment providers; i.e., participating providers
    demonstrating that they serve a minimum of 150 clients per year, as
    indicated by the most recent 12 month reporting period. During the
    2^nd^ and 3^rd^ years of the program, STAR-SI grantees will: (1)
    implement demonstrated improvements in a broader network or networks
    of outpatient treatment providers, e.g., county, region, and/or
    statewide; (2) continue to demonstrate other improvements; and (3)
    expand the number of treatment providers participating in process
    improvement peer learning networks;

-   Establish and maintain, in partnership with NIATx and the identified
    treatment provider partner(s), statewide, regional and/or local
    practitioner peer learning networks, consisting of practitioners
    that are implementing access and retention improvements. NIATx will
    provide the support for State level process improvement coach
    consultation services at a minimum of 50 consultant days per year.
    Process improvement coaches will provide on-site and telephone
    assistance to peer learning networks identified by the grantee.
    Grantees will (1) provide travel expenses for up to eight NIATx
    coach visits per year for peer learning network training and
    technical assistance activities; and (2) host a minimum of two
    within State learning sessions per year for State and treatment
    provider peer network participants;

-   Implement fiscal, regulatory and policy related changes that remove
    barriers and create incentives to improve access and retention
    outcomes;

-   Share information, resources and improvement tools with other
    STAR-SI grantees through participation in NIATx learning
    collaborative activities, e.g., teleconferences, interest circles
    and attendance at the annual NIATx learning collaborative
    conference; and

-   Implement a performance management system to track client access and
    retention, as identified below in Section I-2.4, and monitor the
    implementation of process improvement at both the State and provider
    level.

STAR-SI cooperative agreement funds [may]{.underline} also be used to
carry out any of the activities listed below in order to achieve program
access and retention goals:

-   Needs assessment

-   Strategic planning

-   Financing/coordination of funding streams

-   Organizational/structural change (e.g., to create locus of
    responsibility for a specific issue/population, or to increase
    access to, or efficiency of, services)

-   Development of interagency coordination mechanisms

-   Provider/network development

-   Policy development to support needed service system improvements
    (e.g., rate-setting activities, establishment of standards of care,
    development/revision of credentialing, licensure, or accreditation
    requirements)

-   Quality improvement efforts

-   Performance measurement development

-   Workforce development (e.g., training, support for licensure,
    credentialing, or accreditation)

Please Note: The STAR-SI program does not allow for the conduct of
implementation pilots, i.e., direct provision of clinical services to
clients to evaluate the effectiveness of clinical services.

**2.4 Data and Performance Measurement**

Grantees in the STAR-SI grant program will be required to report
performance on increasing access and retention by using the following
GPRA measures: (1) number of treatment providers participating in
STAR-SI implementation; (2) number of unique client admissions; (3)
client length of stay; and (4) number of units of service provided
between intake and discharge. Grantees will be required to collect this
information using Sections A, J and K of the Core GPRA Client Outcomes
Tool. (See Appendix F). These data will be collected and reported at the
individual client level. Grantees will also be expected to create a
unique program identification number for each program submitting data.
These data will be submitted to CSAT on a regular and on-going basis to
the CSAT GPRA website at
[www.samhsa-gpra.samhsa.gov](http://www.samhsa-gpra.samhsa.gov/). CSAT
expects to use the first three months of data collection to set the
baseline which will be used to measure the program. It is expected that
after this time, change processes will have been implemented and an
increase in all measures stated above should be seen.

In addition, STAR-SI grantees will collect data on at least two State
specific access and/or retention measures, including one measure that
addresses timeliness to treatment, e.g., number of first contacts that
continue to admission, time from first contact to admission, number of
clients that proceed from admission to succeeding units of service. See
Appendix E: "Examples of State Specific Access and Retention Measures."
Grantees will report on the identified State specific measures, data
collection process, and performance outcomes in their semi-annual
progress reports.

**2.5 Evaluation**

Grantees must evaluate their projects, and you are required to describe
your evaluation plans in your application. The evaluation should be part
of a performance management system that is designed to provide regular
feedback to treatment providers and other stakeholders. The evaluation
must include both process and outcome components. Process and outcome
evaluations must measure change relating to project goals and objectives
over time compared to baseline information.

Process components should address issues such as:

-   Was the project implemented in a manner that was consistent with the
    requirements of the RFA?

-   Was the process improvement model implemented with fidelity?

-   Were State-level barriers to access and retention identified, e.g.,
    State regulated data collection requirements, pre-certification
    and/or facility licensure, etc., and how were process improvement
    methods used to identify, implement and sustain improvements?

-   What improvements were identified to address barriers at the State
    and provider levels and how were they implemented?

-   How were key stakeholders involved in the improvement process?

-   What peer learning networks were developed and how are they being
    sustained?

-   How was performance data collected and what quality assurance
    procedures implemented? Did the grantee collect data on at least two
    State specific access and retention performances measures? Did the
    grantee provide performance feedback to treatment providers?

-   Was process improvement implemented with fidelity at the State and
    treatment provider level?

-   To what extent did environmental factors, e.g., changes in provider
    reimbursement rates, budgetary shortfalls, etc., have an impact on
    implementation?

Outcome components should address issues such as:

-   Were there measureable improvements in client access and retention?
    Were there measureable improvements resulting from the State
    specific performance measure(s)?

-   How many improvements were spread to broader networks of treatment
    providers and/or statewide?

-   What was the increase in the number of treatment providers
    participating in process improvement learning networks? How many of
    these providers implemented one or more improvement projects?

-   What effect did contextual factors have on access and retention
    outcomes?

-   How durable were the effects?

All process and outcome evaluation data collected for STAR-SI will be
used for performance monitoring and should be carried out by appropriate
program managers. Independent evaluator services are not an allowable
expense under this RFA. No more than 20 percent of the total grant award
may be used for evaluation/performance tracking activities.

**2.6 Grantee Meetings**

STAR-SI grantees must plan to send a minimum of 5 individuals, including
the Senior Manager/Change Leader, Program Coordinator, and selected
management staff and stakeholders to one grantee meeting each year of
the grant, and you must include funding for this travel in your budget.
At these meetings, grantees will present the results of their projects
and Federal staff will provide technical assistance. Each meeting will
be 3 days. These meetings are usually held in the Washington, D.C., area
and attendance is mandatory.

# II. AWARD INFORMATION

## 1. AWARD AMOUNT

It is expected that up to \$2.2 million will be available to fund up to
7 awards in FY 2006. Annual awards are expected to be \$325,000 per year
in total costs (direct and indirect) for up to 3 years.

**Proposed budgets cannot exceed \$325,000 in any year of the proposed
project.** Annual continuation awards will depend on the availability of
funds, grantee progress in meeting project goals and objectives, and
timely submission of required data and reports.

## 2. FUNDING MECHANISM

Awards will be made as cooperative agreements because of the complexity
of this program and the anticipation of ongoing substantial involvement
of the Federal Government in the transfer of effective practices to the
field.

# 

[Role of Federal Staff:]{.underline}

The CSAT Project Officer will:

-   assist grantees in identifying appropriate information and resources
    for use in their implementation activities;

-   review and approve the performance tracking systems implemented by
    grantees to track access and retention measures;

-   oversee the implementation of peer learning networks that will
    provide technical support to grantees in process improvement methods
    and the implementation of access and retention improvement projects;
    and

-   bridge learning and foster collaboration with related SAMHSA
    programs \-- CSAT's Addiction Technology Transfer Centers and State
    Adolescent Treatment Coordinator programs.

[Role of Grantees:]{.underline}

Grantees are expected to participate in peer learning network activities
and cooperate fully with CSAT staff, its representative contractor(s)
and other program grantees in implementation and evaluation of the
program. Grantees will:

-   participate in the activities of the STAR-SI learning network, as
    directed by the CSAT Project Officer;

-   co-author publications to make the results of the projects available
    to the field;

-   cooperate with CSAT staff and representative contractor(s) in
    accepting guidance and responding to requests for information
    relevant to the program; and

-   comply with all aspects of the terms and conditions of the
    cooperative agreement (to be issued with the award).

# III. ELIGIBILITY INFORMATION 

## 1. ELIGIBLE APPLICANTS

Eligible applicants are States, the District of Columbia, territories,
federally recognized tribes, and tribal organizations. Tribal
organization means the recognized governing body of any Indian tribe;
any legally established organization of Indians which is controlled,
sanctioned, or chartered by such governing body or which is
democratically elected by the adult members of the Indian community to
be served by such organization and which includes the maximum
participation of Indians in all phases of its activities (P.L. 93-638,
as amended). Consortia of tribal organizations are eligible to apply,
but each participating entity must indicate its approval.

Consortia applications from non-tribal entities are not eligible under
this RFA, due to the number and complexity of program requirements and
the limitation on the amount of the awards.

Since this program is designed to facilitate State level implementation
of access and retention improvements, only States, the District of
Columbia, territories, federally recognized tribes and tribal
organizations are eligible to apply.

## 2. COST SHARING

Cost sharing is not required in this program, and applications will not
be screened out on the basis of cost sharing.

**3. OTHER**

**Applications must comply with the following requirements, or they will
be screened out and will not be reviewed:** use of the PHS 5161-1
application; application submission requirements in Section IV-3 of this
document; and formatting requirements provided in Section IV-2.3 of this
document.

# IV. APPLICATION AND SUBMISSION INFORMATION 

**(To ensure that you have met all submission requirements, a checklist
is provided for your use in Appendix A of this document.)**

## 1. ADDRESS TO REQUEST APPLICATION PACKAGE 

> You may request a complete application kit from the National
> Clearinghouse for Alcohol and Drug Information (NCADI) at
> 1-800-729-6686.

You also may download the required documents from the SAMHSA web site at
[[www.samhsa.gov/grants/index.aspx]{.underline}](../www.samhsa.gov/grants/index.aspx)

Additional materials available on this web site include:

-   a technical assistance manual for potential applicants;

-   standard terms and conditions for SAMHSA grants;

-   guidelines and policies that relate to SAMHSA grants (e.g.,
    guidelines on cultural competence, consumer and family
    participation, and evaluation); and

-   enhanced instructions for completing the PHS 5161-1 application.

## 2. CONTENT AND FORM OF APPLICATION SUBMISSION

**2.1 Application Kit**

SAMHSA application kits include the following documents:

-   PHS 5161-1 (revised July 2000) -- Includes the face page, budget
    forms, assurances, certification, and checklist. You must use the
    PHS 5161-1. **Applications that are not submitted on the required
    application form will be screened out and will not be reviewed**.

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-   Request for Applications (RFA) -- Provides specific information
    about the availability of funds along with instructions for
    completing the grant application. This document is the RFA. The RFA
    will be available on the SAMHSA web site
    ([[www.samhsa.gov/grants/index.aspx]{.underline}](../www.samhsa.gov/grants/index.aspx))
    and a synopsis of the RFA is available on the Federal grants web
    site ([www.grants.gov](http://www.grants.gov/)).

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

**2.2 Required Application Components**

To ensure equitable treatment of all applications, applications must be
complete. In order for your application to be complete, it must include
the required ten application components (Face Page, Abstract, Table of
Contents, Budget Form, Project Narrative and Supporting Documentation,
Appendices, Assurances, Certifications, Disclosure of Lobbying
Activities, and Checklist).

-   **Face Page** -- Use Standard Form (SF) 424, which is part of the
    PHS 5161-1. \[Note: Applicants must provide a Dun and Bradstreet
    (DUNS) number to apply for a grant or cooperative agreement from the
    Federal Government. SAMHSA applicants are required to provide their
    DUNS number on the face page of the application. Obtaining a DUNS
    number is easy and there is no charge. To obtain a DUNS number,
    access the Dun and Bradstreet web site at
    [www.dunandbradstreet.com](http://www.dunandbradstreet.com/) or call
    1-866-705-5711. To expedite the process, let Dun and Bradstreet know
    that you are a public/private nonprofit organization getting ready
    to submit a Federal grant application.\]

-   **Abstract** -- Your total abstract should not be longer than 35
    lines. In the first five lines or less of your abstract, write a
    summary of your project that can be used, if your project is funded,
    in publications, reporting to Congress, or press releases.

-   **Table of Contents** -- Include page numbers for each of the major
    sections of your application and for each appendix.

-   **Budget Form** -- Use SF 424A, which is part of the 5161-1. Fill
    out Sections B, C, and E of the SF 424A. A sample budget and
    justification is included in Appendix D of this RFA.

-   **Project Narrative and Supporting Documentation** -- The Project
    Narrative describes your project. It consists of Sections A
    through D. Sections A-D together may not be longer than 30 pages.
    (For example, remember that if your Project Narrative starts on page
    5 and ends on page 35, it is 31 pages long, not 30 pages.) More
    detailed instructions for completing each section of the Project
    Narrative are provided in "Section V---Application Review
    Information" of this document.

    The Supporting Documentation provides additional information
    necessary for the review of your application. This supporting
    documentation should be provided immediately following your Project
    Narrative in Sections E through G. There are no page limits for
    these sections, except for Section G, Biographical Sketches/Job
    Descriptions. Additional instructions for completing these sections
    are included in Section V under "Supporting Documentation."

-   **Appendix** -- Use only the appendix listed below. If your
    application includes any appendices not required in this document,
    they will be disregarded. Do not use more than a total of 15 pages
    for Appendix 1. Do not use appendices to extend or replace any of
    the sections of the Project Narrative. Reviewers will not consider
    them if you do.

    -   *Appendix 1*: Letters of Commitment/Coordination/Support

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-   **Assurances** -- Non-Construction Programs. Use Standard Form 424B
    found in PHS 5161-1.

-   **Certifications** - Use the "Certifications" forms found in PHS
    5161-1.

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-   **Disclosure of Lobbying Activities** -- Use Standard Form LLL found
    in the PHS 5161-1. Federal law prohibits the use of appropriated
    funds for publicity or propaganda purposes, or for the preparation,
    distribution, or use of the information designed to support or
    defeat legislation pending before the Congress or State
    legislatures. This includes "grass roots" lobbying, which consists
    of appeals to members of the public suggesting that they contact
    their elected representatives to indicate their support for or
    opposition to pending legislation or to urge those representatives
    to vote in a particular way.

-   **Checklist** -- Use the Checklist found in PHS 5161-1. The
    Checklist ensures that you have obtained the proper signatures,
    assurances and certifications and is the last page of your
    application.

**2.3 Application Formatting Requirements**

Applicants also must comply with the following basic application
requirements. Applications that do not comply with these requirements
will be screened out and will not be reviewed.

-   Information provided must be sufficient for review.

-   Text must be legible. For Project Narratives submitted
    electronically in Microsoft Word, see separate requirements below
    under "Guidance for Electronic Submission of Applications."

• Type size in the Project Narrative cannot exceed an average of 15
characters per

inch, as measured on the physical page. (Type size in charts, tables,
graphs, and

footnotes will not be considered in determining compliance.)

• Text in the Project Narrative cannot exceed 6 lines per vertical inch.

-   Paper must be white paper and 8.5 inches by 11.0 inches in size.

-   To ensure equity among applications, the amount of space allowed for
    the Project Narrative cannot be exceeded. For Project Narratives
    submitted electronically in Microsoft Word, see separate
    requirements below under "Guidance for Electronic Submission of
    Applications."

• Applications would meet this requirement by using all margins (left,
right, top, bottom) of at least one inch each, and adhering to the
30-page limit for the Project Narrative.

• Should an application not conform to these margin or page limits,
SAMHSA will use the following method to determine compliance: The total
area of the Project Narrative (excluding margins, but including charts,
tables, graphs and footnotes) cannot exceed 58.5 square inches
multiplied by 30. This number represents the full page less margins,
multiplied by the total number of allowed pages.

• Space will be measured on the physical page. Space left blank within
the Project Narrative (excluding margins) is considered part of the
Project Narrative, in determining compliance.

To facilitate review of your application, follow these additional
guidelines. Failure to adhere to the following guidelines will not, in
itself, result in your application being screened out and returned
without review. However, following these guidelines will help reviewers
to consider your application.

-   Pages should be typed single-spaced in black ink, with one column
    per page. Pages should not have printing on both sides.

-   Please number pages consecutively from beginning to end so that
    information can be located easily during review of the application.
    The cover page should be page 1, the abstract page should be page 2,
    and the table of contents page should be page 3. Appendices should
    be labeled and separated from the Project Narrative and budget
    section, and the pages should be numbered to continue the sequence.

-   The page limit of a total of 15 pages for Appendix 1 should not be
    exceeded.

-   Send the original application and two copies to the mailing address
    in Section IV-6.1 of this document. Please do not use staples, paper
    clips, and fasteners. Nothing should be attached, stapled, folded,
    or pasted. Do not use heavy or lightweight paper or any material
    that cannot be copied using automatic copying machines. Odd-sized
    and oversized attachments such as posters will not be copied or sent
    to reviewers. Do not include videotapes, audiotapes, or CD-ROMs.

[Guidance for Electronic Submission of Applications]{.underline}

SAMHSA offers the opportunity for you to submit your application to us
either in electronic or paper format. Register one time, and Grants.gov
will generate your information for future applications so you don't have
to re-enter it. Built-in error-checking increases the completeness and
accuracy of your application. Electronic submission is voluntary. No
review points will be added or deducted, regardless of whether you use
the electronic or paper format.

To submit an application electronically, you must use the
[www.Grants.gov](http://www.Grants.gov/) apply site. You will be able to
download a copy of the application package from
[www.Grants.gov](http://www.Grants.gov/), complete it off-line, and then
upload and submit the application via the Grants.gov site. E-mail
submissions will not be accepted.

You may search the Grants.gov site for the downloadable application
package, by the funding announcement number (called the opportunity
number) or by the Catalogue of Federal Domestic Assistance (CFDA)
number. You can find the CFDA number on the first page of the funding
announcement.

You must follow the instructions in the User Guide available at the
[www.Grants.gov](http://www.Grants.gov/) apply site, on the Customer
Support tab. In addition to the User Guide, you may wish to use the
following sources for help:

-   By e-mail: <support@Grants.gov>

-   By phone: 1-800-518-4726 (1-800-518-GRANTS). The Customer Support
    Center is open from 7:00 a.m. to 9:00 p.m. Eastern Time, Monday
    through Friday.

**If this is the first time you have submitted an application through
Grants.gov, you must complete four separate registration processes
before you can submit your application. Allow at least two weeks (10
business days) for these registration processes, prior to submitting
your application.** The processes are: DUNS Number registration, Central
Contractor Registry (CCR) registration, Credential Provider
registration, and Grants.gov registration.

**It is strongly recommended that you submit your grant application
using Microsoft Office products (e.g., Microsoft Word, Microsoft Excel,
etc.).** If you do not have access to Microsoft Office products, you may
submit a PDF file. Directions for creating PDF files can be found on the
Grants.gov Web site. Use of file formats other than Microsoft Office or
PDF may result in your file being unreadable by our staff.

The Project Narrative must be a separate document in the electronic
submission. Formatting requirements for SAMHSA grant applications are
described above, and in Appendix A of this announcement. These
requirements also apply to applications submitted electronically, with
the following exceptions only for Project Narratives submitted
electronically in Microsoft Word. These requirements help to ensure the
accurate transmission and equitable treatment of applications.

-   *Text legibility:* Use a font of Times New Roman 12, line spacing of
    single space, and all margins (left, right, top, bottom) of one inch
    each. Adhering to these standards will help to ensure the accurate
    transmission of your document. If the type size in the Project
    Narrative of an electronic submission exceeds 15 characters per
    inch, or the text exceeds 6 lines per vertical inch, SAMHSA will
    reformat the document to Times New Roman 12, with line spacing of
    single space. Please note that this may alter the formatting of your
    document, especially for charts, tables, graphs, and footnotes.

-   *Amount of space allowed for Project Narrative:* The Project
    Narrative for an electronic submission may not exceed 15,450 words.
    If the Project Narrative for an electronic submission exceeds the
    word limit and exceeds the allowed space as defined in Appendix A,
    then **any part of the Project Narrative in excess of these limits
    will not be submitted to review**. To determine the number of words
    in your Project Narrative document in Microsoft Word, select
    file/properties/statistics.

While keeping the Project Narrative as a separate document, please
consolidate all other materials in your application to ensure the fewest
possible number of attachments. Ensure all pages in your application are
numbered consecutively, with the exception of the standard forms in the
PHS-5161 application package. Please name and number your attachments,
indicating the order in which they should be assembled. Failure to
comply with these requirements may affect the successful transmission
and consideration of your application.

Applicants are strongly encouraged to submit their applications to
Grants.gov early enough to resolve any unanticipated difficulties prior
to the deadline. You may also submit a back-up paper submission of your
application. Any such paper submission must be received in accordance
with the requirements for timely submission detailed in Section IV-3 of
this announcement. The paper submission must be clearly marked:
**"Back-up for electronic submission."** The paper submission must
conform with all requirements for non-electronic submissions. If both
electronic and back-up paper submissions are received by the deadline,
the electronic version will be considered the official submission.

After you electronically submit your application, you will receive an
automatic acknowledgement from Grants.gov that contains a Grants.gov
tracking number. It is important that you retain this number. **Include
the Grants.gov tracking number in the top right corner of the face page
for any paper submission.**

The Grants.gov Web site does not accept electronic signatures at this
time. Therefore, you must submit a signed paper original of the face
page (SF 424), the assurances (SF 424B), and the certifications, and
hard copy of any other required documentation that cannot be submitted
electronically. **You must include the Grants.gov tracking number for
your application on these documents with original signatures, on the top
right corner of the face page, and send the documents to the following
address. The documents must be received at the following address within
5 business days after your electronic submission.** Delays in receipt of
these documents may impact the score your application receives or the
ability of your application to be funded.

**For United States Postal Service:**

Crystal Saunders, Director of Grant Review

Office of Program Services

Substance Abuse and Mental Health Services Administration

Room 3-1044

1 Choke Cherry Road

Rockville, MD **20857**

ATTN: Electronic Applications

**For other delivery service (DHL, Federal Express, United Parcel
Service):**

Crystal Saunders, Director of Grant Review

Office of Program Services

Substance Abuse and Mental Health Services Administration

Room 3-1044

1 Choke Cherry Road

Rockville, MD **20850**

ATTN: Electronic Applications

If you require a phone number for delivery, you may use (240) 276-1199.

## 3. SUBMISSION DATES AND TIMES 

Applications are due by close of business on **March 24, 2006**. **Hand
carried applications will not be accepted. Applications may be shipped
using only DHL, Federal Express (FedEx), United Parcel Service (UPS), or
the United States Postal Service (USPS).**

Your application must be received by the application deadline, or you
must have proof of its timely submission as specified below.

-   **For packages submitted via DHL, Federal Express (FedEx), or United
    Parcel Service (UPS), proof of timely submission shall be the date
    on the tracking label affixed to the package by the carrier upon
    receipt by the carrier. That date must be at least 24 hours prior to
    the application deadline. The date affixed to the package by the
    applicant will not be sufficient evidence of timely submission.**

-   For packages submitted via the United States Postal Service (USPS),
    proof of timely submission shall be a postmark not later than 1 week
    prior to the application deadline, and the following upon request by
    SAMHSA:

    -   proof of mailing using USPS Form 3817 (Certificate of Mailing),
        or

    -   a receipt from the Post Office containing the post office name,
        location, and date and time of mailing.

You will be notified by postal mail that your application has been
received.

**Applications not meeting the timely submission requirements above will
not be considered for review.** Please remember that mail sent to
Federal facilities undergoes a security screening prior to delivery.
Allow sufficient time for your package to be delivered.

If an application is mailed to a location or office (including room
number) that is not designated for receipt of the application, and that
results in the designated office not receiving your application in
accordance with the requirements for timely submission, it will cause
the application to be considered late and ineligible for review.

SAMHSA will not accept or consider any applications sent by facsimile.

SAMHSA is collaborating with [www.Grants.gov](http://www.Grants.gov/) to
accept electronic submission of applications. Please refer to Section
IV-2.3 above for "Guidance for Electronic Submission of Applications."

## 4. INTERGOVERNMENTAL REVIEW (E.O. 12372) REQUIREMENTS

Executive Order 12372, as implemented through Department of Health and
Human Services (DHHS) regulation at 45 CFR Part 100, sets up a system
for State and local review of applications for Federal financial
assistance. A current listing of State Single Points of Contact (SPOCs)
is included in the application kit and can be downloaded from the Office
of Management and Budget (OMB) web site at
[www.whitehouse.gov/omb/grants/spoc.html](http://www.whitehouse.gov/omb/grants/spoc.html).

-   Check the list to determine whether your State participates in this
    program. You **do not** need to do this if you are a federally
    recognized Indian tribal government.

-   If your State participates, contact your SPOC as early as possible
    to alert him/her to the prospective application(s) and to receive
    any necessary instructions on the State's review process.

-   For proposed projects serving more than one State, you are advised
    to contact the SPOC of each affiliated State.

-   The SPOC should send any State review process recommendations to the
    following address within 60 days of the application deadline:

> **For United States Postal Service:**
>
> Crystal Saunders, Director of Grant Review
>
> Office of Program Services
>
> Substance Abuse and Mental Health Services Administration
>
> Room 3-1044
>
> 1 Choke Cherry Road
>
> Rockville, MD **20857**

ATTN: SPOC -- Funding Announcement No. **TI-06-006**

> **For other delivery service:**
>
> Crystal Saunders, Director of Grant Review
>
> Office of Program Services
>
> Substance Abuse and Mental Health Services Administration
>
> Room 3-1044
>
> 1 Choke Cherry Road
>
> Rockville, MD **20850**
>
> ATTN: SPOC -- Funding Announcement No. **TI-06-006**

## 5. FUNDING LIMITATIONS/RESTRICTIONS 

Cost principles describing allowable and unallowable expenditures for
Federal grantees, including SAMHSA grantees, are provided in the
following documents, which are available at
<http://www.hhs.gov/grantsnet/roadmap/index.html>:

-   Institutions of Higher Education: OMB Circular A-21

-   State and Local Governments and Federally Recognized Indian Tribal
    Governments: OMB Circular A-87

-   Nonprofit Organizations: OMB Circular A-122

-   Hospitals: 45 CFR Part 74, Appendix E

In addition, SAMHSA's Strengthening Treatment Access and Retention --
State Implementation (STAR-SI) grant recipients must comply with the
following funding restrictions:

-   Grant funds must be used for purposes supported by the program.

-   No more than 20 percent of the grant award may be used for
    evaluation and data collection expenses.

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-   Grant funds may not be used to pay for the purchase or construction
    of any building or structure to house any part of the grant project.
    (Applicants may request up to \$75,000 for renovations and
    alterations of existing facilities, if necessary and appropriate to
    the project.)

SAMHSA will not accept a "research" indirect cost rate. The grantee must
use the "other sponsored program rate" or the lowest rate available.

## 6. OTHER SUBMISSION REQUIREMENTS

**6.1 Where to Send Applications**

Guidance for Electronic Submission of Applications is contained in
Section IV-2.3 of this announcement. Following are instructions for
submission of paper applications.

Send applications to the following address:

> **For United States Postal Service:**
>
> Crystal Saunders, Director of Grant Review
>
> Office of Program Services
>
> Substance Abuse and Mental Health Services Administration
>
> Room 3-1044
>
> 1 Choke Cherry Road
>
> Rockville, MD **20857**
>
> **For other delivery service:**
>
> Crystal Saunders, Director of Grant Review
>
> Office of Program Services
>
> Substance Abuse and Mental Health Services Administration
>
> Room 3-1044
>
> 1 Choke Cherry Road
>
> Rockville, MD **20850**

Do not send applications to other agency contacts, as this could delay
receipt. Be sure to include **STAR-SI** and **TI-06-006** in item number
10 on the face page any paper applications. If you require a phone
number for delivery, you may use (240) 276-1199.

**6.2 How to Send Applications**

SAMHSA is collaborating with [www.Grants.gov](http://www.Grants.gov/) to
accept electronic submission of applications. Please refer to Section
IV-2.3 of this announcement for "Guidance for Electronic Submission of
Applications." Following are instructions for submission of paper
applications.

Mail or deliver an original application and 2 copies (including
appendices) to the mailing address provided above, according to the
instructions in Section IV-3. The original and copies must not be bound.
Do not use staples, paper clips, or fasteners. Nothing should be
attached, stapled, folded, or pasted.

**Hand carried applications will not be accepted. Applications may be
shipped using only DHL, Federal Express (FedEx), United Parcel Service
(UPS), or the United States Postal Service (USPS).**

**SAMHSA will not accept or consider any applications sent by
facsimile.**

# V. APPLICATION REVIEW INFORMATION

## 1. EVALUATION CRITERIA 

Your application will be reviewed and scored according to the
[quality]{.underline} of your response to the requirements listed below
for developing the Project Narrative (Sections A-D). These sections
describe what you intend to do with your project.

-   In developing the Project Narrative section of your application, use
    these instructions which have been tailored to this program. **These
    are to be used instead of the "Program Narrative" instructions found
    in the PHS 5161-1**.

-   The Project Narrative (Sections A-D) together may be no longer than
    30 pages.

-   You must use the four sections/headings listed below in developing
    your Project Narrative. Be sure to place the required information in
    the correct section, **or it will not be considered**. Your
    application will be scored according to how well you address the
    requirements for each section of the Project Narrative.

    -   The Supporting Documentation you provide in Sections E-G and
        Appendix 1 will be considered by reviewers in assessing your
        response, along with the material in the Project Narrative.

    -   The number of points after each heading below is the maximum
        number of points a review committee may assign to that section
        of your Project Narrative. Bullet statements in each section do
        not have points assigned to them. They are provided to invite
        the attention of applicants and reviewers to important areas
        within each section.

**Section A: Statement of Need (10 points)**

-   Document the need to improve access and retention to outpatient
    treatment and for an enhanced infrastructure to address this need.
    State applicants should provide aggregate baseline data for all
    outpatient providers (ASAM Level of Care 1) in the State for the
    most recent 12 month period (either calendar or fiscal year; please
    indicate which it is and the associated time period) for the
    following measures: (a) number of unduplicated client
    admissions; (b) median length of stay in outpatient treatment; (c)
    percentage of admitted outpatients who remain in care after 28 days;
    and (d) the percentage of admitted outpatient clients who remain in
    care after 56 days. If data is not currently available for one or
    more of these measures, provide equivalent data that are available
    and specify what actions you plan to take prior to project start up
    to demonstrate the capability to collect these measures. Tribal
    applicants should provide similar data/documentation relating to
    access and retention for the territory they cover.

[]{.mark}

-   Describe the service gaps, barriers, and other problems related to
    client access and retention and the need for infrastructure
    development to address the identified gaps, barriers and/or
    problems.

**Section B: Proposed Approach (35 points)**

-   Clearly state the purpose of the proposed project, with goals and
    objectives. Describe how achievement of goals will increase client
    access and retention in your State/Tribal territory.

-   Describe the proposed project. In the description of the project,
    address how you plan to implement each of the required activities
    listed in Section I-2.3 of this RFA. Indicate how your proposed
    implementation plan will meet the goals and objectives of the
    program.

-   Demonstrate your understanding of the application of the process
    improvement model by conducting a process improvement "walkthrough"
    related to a barrier that was identified in Section A: Statement of
    Need, and describing the walkthrough process and outcome(s). (See
    "Resource Guide to Process Improvement//How to Conduct a
    Walkthrough" at www.niatx.net).

-   Identify 5 or more outpatient treatment providers that will
    demonstrate access and retention improvements and provide the
    following information for each pilot provider: (1) name of the
    organization and individual(s) who will function as STAR-SI program
    lead and change leader; (2) number of unduplicated client admissions
    per year; and (3) description of organization structure, including
    the number and type of outpatient treatment units and the
    demographic characteristics of population(s) served, i.e., gender,
    age, race. In Appendix 1 of your application, include a letter of
    commitment to participate in the project from the director of each
    of the identified treatment providers.

-   Describe your plan to implement demonstrated access and retention
    improvements in a broader network of outpatient treatment providers
    and to expand the operation of peer learning networks to meet
    implementation needs.

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-   Identify the outpatient treatment providers and fiscal
    intermediaries, if applicable, that will partner with the applicant
    in the design and implementation of the project. Describe how
    program partners participated in preparation of the application and
    identify the roles and responsibilities of partner representatives
    on the STAR-SI program management team. Demonstrate their commitment
    to the project. Include letters of commitment/coordination/support
    from the identified partners in Appendix 1 of the application.

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-   Describe the potential barriers to successful conduct of the
    proposed project and how you will overcome them.

-   Describe existing policies and/or program initiatives to ensure
    delivery of culturally appropriate/competent services and provide
    one example of how an improvement related to the delivery of
    culturally competent services could drive improvements in client
    access and/or retention. SAMHSA's guidelines for cultural competence
    can be found on the SAMHSA web site at
    [www.samhsa.gov](http://www.samhsa.gov/). Click on the
    "Grants/SAMHSA's Supporting Grant Information/Useful Information for
    Applicants/Guidelines and Resources for Grant Applicants."

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-   Describe your plan to ensure project sustainability when funding for
    this project ends. Also describe how program continuity will be
    maintained when there is a change in the operational environment
    (e.g., staff turnover, change in project leadership) to ensure
    stability over time.

**Section C: Staff, Management, and Relevant Experience (25 points)**

-   Identify the key staff that will participate in the project,
    including the SSA Director, and indicate the role of each and their
    level of effort and qualifications. Describe the experience, skills
    and leadership capabilities of the designated senior manager/change
    leader and his/her past experience interacting with the SSA Director
    and senior management; clearly identify how staffing
    responsibilities will be reallocated to ensure a minimum of 30
    percent of a full time, existing senior level manager/change leader
    position is dedicated to the project and can be sustained throughout
    the project period. Identify the senior managers that will provide
    support to the change leader and describe their role in the project.
    Describe the experience, skills and capabilities of the designated
    program coordinator position, including demonstrated experience and
    skills to facilitate team building and communicate effectively with
    management staff and identified stakeholders; clearly identify how
    staffing responsibilities will be reallocated to ensure a minimum of
    50 percent of a full time position is dedicated to the program
    coordinator to the project and can be sustained throughout the
    project.

-   Provide a realistic time line for the project (chart or graph)
    showing key activities, milestones, and staff responsible for each
    activity. \[Note: The time line should be part of the Project
    Narrative. It should not be placed in an appendix.\]

-   Discuss the capability and experience of the applicant organization
    and other participating organizations with similar projects.
    Describe the management and staffing plan for the project, including
    detailed information on the staffing and resources allocated to the
    operation of the proposed peer learning network(s) and stakeholder
    participation in the design and implementation of the program.

-   Describe the resources available for the proposed project (e.g.,
    facilities, equipment).

**Section D: Evaluation and Data (30 points)**

-   Describe the process and outcome evaluation. Include specific
    performance measures and target outcomes related to the goals and
    objectives identified for the project in Section B of your Project
    Narrative.

-   Document your ability to collect and report on the required
    performance measures as specified in Section I-2.4 of this document,
    including data required by SAMHSA to meet GPRA requirements. Specify
    and document your ability to collect and report on a minimum of two
    State specific access and retention measures, including one measure
    that addresses timeliness to treatment.

-   Describe plans for collection, management, analysis, and reporting
    of performance data.

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

**SUPPORTING DOCUMENTATION**

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

**Section F:** Budget Justification, Existing Resources, Other Support.
You must provide a narrative justification of the items included in your
proposed budget, as well as a description of existing resources and
other support you expect to receive for the proposed project. Be sure to
show that no more than 20 percent of the total grant award will be used
for data collection and evaluation, including GPRA. An illustration of a
budget and narrative justification is included in Appendix D of this
document.

**Section G:** Biographical Sketches and Job Descriptions.

-   Include a biographical sketch for the Project Director and other key
    positions. Each sketch should be 2 pages or less. If the person has
    not been hired, include a position description and/or letter of
    commitment with a current biographical sketch from the individual.

-   Include job descriptions for key personnel. Job descriptions should
    be no longer than 1 page each.

-   Information on what should be included in biographical sketches and
    job descriptions can be found on page 22, Item 6, in the Program
    Narrative section of the PHS 5161-1 instruction page, available at
    [www.hhs.gov/forms/PHS-5161-1.doc](http://www.hhs.gov/forms/PHS-5161-1.doc).

## 2. REVIEW AND SELECTION PROCESS 

SAMHSA applications are peer-reviewed according to the review criteria
listed above. For those programs where the individual award is over
\$100,000, applications must also be reviewed by the appropriate
National Advisory Council.

Decisions to fund a grant are based on:

-   the strengths and weaknesses of the application as identified by
    peer reviewers and, when applicable, approved by the Center for
    Substance Abuse Treatment's National Advisory Council;

-   availability of funds; and

-   equitable distribution of awards in terms of geography (including
    urban, rural and remote settings) and balance among target
    populations and program size.

SAMHSA/CSAT will make no more than one award per State or tribe.

# VI. AWARD ADMINISTRATION INFORMATION

## 1. AWARD NOTICES

After your application has been reviewed, you will receive a letter from
SAMHSA through postal mail that describes the general results of the
review, including the score that your application received.

If you are approved for funding, you will receive an **additional**
notice, the Notice of Grant Award, signed by SAMHSA's Grants Management
Officer. The Notice of Grant Award is the sole obligating document that
allows the grantee to receive Federal funding for work on the grant
project. It is sent by postal mail and is addressed to the contact
person listed on the face page of the application.

If you are not funded, you can re-apply if there is another receipt date
for the program.

## 2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS 

[]{.mark}

-   Successful applicants must comply with all terms and conditions of
    the grant award. SAMHSA's standard terms and conditions are
    available on the SAMHSA web site at
    [www.samhsa.gov/grants/generalinfo/grants_management.aspx](http://www.samhsa.gov/grants/generalinfo/grants_management.aspx).

-   Successful applicants must also comply with the administrative
    requirements outlined in 45 CFR Part 74 or 45 CFR Part 92, as
    appropriate. For more information see the SAMHSA web site
    (<http://www.samhsa.gov/Grants/generalinfo/grant_reqs.aspx> ).

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-   Depending on the nature of the specific funding opportunity and/or
    the proposed project as identified during review, additional terms
    and conditions may be negotiated with the grantee prior to grant
    award. These may include, for example:

    -   requirements relating to additional data collection and
        reporting;

    -   requirements relating to participation in a cross-site
        evaluation; or

    -   requirements to address problems identified in review of the
        application.

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-   Successful applicants will be held accountable for the information
    provided in the application relating to performance targets. SAMHSA
    program officials will consider your progress in meeting goals and
    objectives, as well as your failures and strategies for overcoming
    them, when making an annual recommendation to continue the grant and
    the amount of any continuation award. Failure to meet stated goals
    and objectives may result in suspension or termination of the grant
    award, or in reduction or withholding of continuation awards.

-   Grant funds cannot be used to supplant current funding of existing
    activities. "Supplant" is defined as replacing funding of a
    recipient's existing program with funds from a Federal grant.

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-   In an effort to improve access to funding opportunities for
    applicants, SAMHSA is participating in the U.S. Department of Health
    and Human Services "Survey on Ensuring Equal Opportunity for
    Applicants." This survey is included in the application kit for
    SAMHSA grants and is posted on the SAMHSA web site. Applicants are
    encouraged to complete the survey and return it, using the
    instructions provided on the survey form.

## 3. REPORTING REQUIREMENTS 

## 

**3.1 Progress and Financial Reports**

-   Grant performance will require the submission of semi-annual and
    final progress reports, as well as annual and final financial status
    reports.

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-   Because SAMHSA is extremely interested in ensuring that
    infrastructure development and enhancement efforts can be sustained,
    your progress reports should explain plans to ensure the
    sustainability (see Glossary) of efforts initiated under this grant.

-   SAMHSA will provide guidelines and requirements for these reports to
    grantees at the time of award and at the initial grantee orientation
    meeting after award. SAMHSA staff will use the information contained
    in the reports to determine the grantee's progress toward meeting
    its goals.

**3.2 Government Performance and Results Act**

The Government Performance and Results Act (GPRA) mandates
accountability and performance-based management by Federal agencies. To
meet the GPRA requirements, SAMHSA must collect performance data (i.e.,
"GPRA data") from grantees. The performance requirements for SAMHSA's
Strengthening Treatment Access and Retention -- State Implementation
(STAR-SI) grant program are described in Section I-2.4 of this document
under "Data and Performance Measurement."

**3.3 Publications**

If you are funded under this grant program, you are required to notify
the Government Project Officer (GPO) and SAMHSA's Publications Clearance
Officer (240-276-2130) of any materials based on the SAMHSA-funded
project that are accepted for publication.

In addition, SAMHSA requests that grantees:

-   Provide the GPO and SAMHSA Publications Clearance Officer with
    advance copies of publications.

-   Include acknowledgment of the SAMHSA grant program as the source of
    funding for the project.

-   Include a disclaimer stating that the views and opinions contained
    in the publication do not necessarily reflect those of SAMHSA or the
    U.S. Department of Health and Human Services, and should not be
    construed as such.

SAMHSA reserves the right to issue a press release about any publication
deemed by SAMHSA to contain information of program or policy
significance to the substance abuse treatment/substance abuse
prevention/mental health services community.

# VII. AGENCY CONTACTS

For questions about program issues, contact:

Suzanne Cable

Division of Services Improvement, Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Room 5-1110

Rockville, Maryland 20857

\(240\) 276-1568

<suzanne.cable@samhsa.hhs.gov>

Frances Cotter

Division of Services Improvement, Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Room 5-1089

Rockville, Maryland 20857

\(240\) 276-1569

<frances.cotter@samhsa.hhs.gov>

For questions on grants management issues, contact:

Kimberly Pendleton

Office of Program Services, Division of Grants Management

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Room 7-1097

Rockville, Maryland 20857

\(240\) 276-1421

<kimberly.pendleton@samhsa.hhs.gov>

### Appendix A -- Checklist for Formatting Requirements and Screenout Criteria for SAMHSA Grant Applications

*SAMHSA's goal is to review all applications submitted for grant
funding. However, this goal must be balanced against SAMHSA's obligation
to ensure equitable treatment of applications. For this reason, SAMHSA
has established certain formatting requirements for its applications.
**If you do not adhere to these requirements, your application will be
screened out and returned to you without review.***

-   Use the PHS 5161-1 application.

-   Applications must be received by the application deadline or have
    proof of timely submission, as detailed in Section IV-3 of the grant
    announcement.

-   Information provided must be sufficient for review.

-   Text must be legible. (For Project Narratives submitted
    electronically in Microsoft Word, see separate requirements in
    Section IV-2.3 of this announcement under "Guidance for Electronic
    Submission of Applications.")

• Type size in the Project Narrative cannot exceed an average of 15
characters per

inch, as measured on the physical page. (Type size in charts, tables,
graphs, and

footnotes will not be considered in determining compliance.)

• Text in the Project Narrative cannot exceed 6 lines per vertical inch.

-   Paper must be white paper and 8.5 inches by 11.0 inches in size.

-   To ensure equity among applications, the amount of space allowed for
    the Project Narrative cannot be exceeded. (For Project Narratives
    submitted electronically in Microsoft Word, see separate
    requirements in Section IV-2.3 of this announcement under "Guidance
    for Electronic Submission of Applications.")

• Applications would meet this requirement by using all margins (left,
right, top, bottom) of at least one inch each, and adhering to the page
limit for the Project Narrative stated in the specific funding
announcement.

• Should an application not conform to these margin or page limits,
SAMHSA will use the following method to determine compliance: The total
area of the Project Narrative (excluding margins, but including charts,
tables, graphs and footnotes) cannot exceed 58.5 square inches
multiplied by the page limit. This number represents the full page less
margins, multiplied by the total number of allowed pages.

• Space will be measured on the physical page. Space left blank within
the Project Narrative (excluding margins) is considered part of the
Project Narrative, in determining compliance.

*To facilitate review of your application, follow these additional
guidelines. Failure to adhere to the following guidelines will not, in
itself, result in your application being screened out and returned
without review. However, the information provided in your application
must be sufficient for review. Following these guidelines will help
ensure your application is complete, and will help reviewers to consider
your application.*

-   The 10 application components required for SAMHSA applications
    should be included. These are:

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```
-   Face Page (Standard Form 424, which is in PHS 5161-1)

-   Abstract

-   Table of Contents

-   Budget Form (Standard Form 424A, which is in PHS 5161-1)

-   Project Narrative and Supporting Documentation

-   Appendices

-   Assurances (Standard Form 424B, which is in PHS 5161-1)

-   Certifications (a form within PHS 5161-1)

-   Disclosure of Lobbying Activities (Standard Form LLL, which is in
    PHS 5161-1)

-   Checklist (a form in PHS 5161-1)

```{=html}
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```
-   Applications should comply with the following requirements:

```{=html}
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```
-   Budgetary limitations as specified in Section I, II, and IV-5 of
    this announcement.

-   Documentation of nonprofit status as required in the PHS 5161-1.

```{=html}
<!-- -->
```
-   Pages should be typed single-spaced in black ink, with one column
    per page. Pages should not have printing on both sides.

-   Please number pages consecutively from beginning to end so that
    information can be located easily during review of the application.
    The cover page should be page 1, the abstract page should be page 2,
    and the table of contents page should be page 3. Appendices should
    be labeled and separated from the Project Narrative and budget
    section, and the pages should be numbered to continue the sequence.

-   The page limits for Appendices stated in the specific funding
    announcement should not be exceeded.

-   Send the original application and two copies to the mailing address
    in Section IV-6.1 of this document. Please do not use staples, paper
    clips, and fasteners. Nothing should be attached, stapled, folded,
    or pasted. Do not use heavy or lightweight paper or any material
    that cannot be copied using automatic copying machines. Odd-sized
    and oversized attachments such as posters will not be copied or sent
    to reviewers. Do not include videotapes, audiotapes, or CD-ROMs.

### Appendix B - Glossary

**[Best Practice:]{.underline}** Best practices are practices that
incorporate the best objective information currently available regarding
effectiveness and acceptability.

**[Catchment Area:]{.underline}** A catchment area is the geographic
area from which the target population to be served by a program will be
drawn.

**[Cooperative Agreement:]{.underline}** A cooperative agreement is a
form of Federal grant. Cooperative agreements are distinguished from
other grants in that, under a cooperative agreement, substantial
involvement is anticipated between the awarding office and the recipient
during performance of the funded activity. This involvement may include
collaboration, participation, or intervention in the activity. HHS
awarding offices use grants or cooperative agreements (rather than
contracts) when the principal purpose of the transaction is the transfer
of money, property, services, or anything of value to accomplish a
public purpose of support or stimulation authorized by Federal statute.
The primary beneficiary under a grant or cooperative agreement is the
public, as opposed to the Federal Government.

**[Fidelity:]{.underline}** Fidelity is the degree to which a specific
implementation of a program or practice resembles, adheres to, or is
faithful to the evidence-based model on which it is based. Fidelity is
formally assessed using rating scales of the major elements of the
evidence-based model. A toolkit on how to develop and use fidelity
instruments is available from the SAMHSA-funded Evaluation Technical
Assistance Center at [http://tecathsri.org](http://tecathsri.org/) or by
calling (617) 876-0426.

**[Grant:]{.underline}** A grant is the funding mechanism used by the
Federal Government when the principal purpose of the transaction is the
transfer of money, property, services, or anything of value to
accomplish a public purpose of support or stimulation authorized by
Federal statute. The primary beneficiary under a grant or cooperative
agreement is the public, as opposed to the Federal Government.

**[Practice]{.underline}:** A practice is any activity, or collective
set of activities, intended to improve outcomes for people with or at
risk for substance abuse and/or mental illness. Such activities may
include direct service provision, or they may be supportive activities,
such as efforts to improve access to and retention in services,
organizational efficiency or effectiveness, community readiness,
collaboration among stakeholder groups, education, awareness, training,
or any other activity that is designed to improve outcomes for people
with or at risk for substance abuse or mental illness.

**[Practice Support System]{.underline}:** This term refers to
contextual factors that affect practice delivery and effectiveness in
the pre-adoption phase, delivery phase, and post-delivery phase, such as
a) community collaboration and consensus building, b) training and
overall readiness of those implementing the practice, and c) sufficient
ongoing supervision for those implementing the practice.

#### Stakeholder: A stakeholder is an individual, organization, constituent group, or other entity that has an interest in and will be affected by a proposed grant project.

**[Sustainability:]{.underline}** Sustainability is the ability to
continue a program or practice after SAMHSA grant funding has ended.

**[Target Population:]{.underline}** The target population is the
specific population of people whom a particular program or practice is
designed to serve or reach.

**[Wraparound Service:]{.underline}** Wraparound services are
non-clinical supportive services---such as child care, vocational,
educational, and transportation services---that are designed to improve
the individual's access to and retention in the proposed project.

### Appendix C --Resources

Gustafson, D. & Hundt, A. (1995). Findings of innovation research
applied to quality management principles for health care. *Health Care
Management Review**,** 20*(2), 10-27.

Juran J., Gryna F. (1988). *Juran's Quality Control Handbook*. (4^th^
ed.), McGraw-Hill Book Company.

Kaynak H. (2003). The relationship between total quality management
practices and their effects on firm performance. *Journal of Operations
Management*, 21(4): 405-435.

Pearson ML, Wu S, Schaefer AB, Shortell SM, Mendel PJ, Marsteller JA,
Louis TA, Rosen M, & Keeler, EB. (2005). Assessing the Implementation of
the Chronic Care Model in Quality Improvement Collaboratives. *Health
Services Research*, 40(4), 978-996.

Ragsdale MA, Mueller J. (2005) Plan, Do, Study, Act Model to Improve an
Orientation Program. *Journal of Nurse Care Quality*, 20, 268-272.

SAMHSA Office of Applied Studies (2002a) National Survey of Substance
Abuse Treatment Services (N-SSATS); (reference also found in McLellan in
"Reconsidering the Evaluation of addiction Treatment: From Retrospective
Follow-up to Concurrent Recovery Monitoring" Horizens Review, 2005
Society for the Study of Addition)

### Appendix D -- Sample Budget and Justification

**ILLUSTRATION OF A SAMPLE DETAILED BUDGET AND**

**NARRATIVE JUSTIFICATION TO ACCOMPANY**

**SF 424A: SECTION B FOR 01 BUDGET PERIOD**

**[OBJECT CLASS CATEGORIES]{.underline}**

**[Personnel]{.underline}**

**Job Annual Level of Salary being**

**Title** **Name Salary Effort Requested**

Project

Director J. Doe \$30,000 1.0 \$30,000

Secretary Unnamed \$18,000 0.5 \$ 9,000

Counselor R. Down \$25,000 1.0 \$25,000

> **Enter Personnel subtotal on 424A, Section B, 6.a. \$64,000**

**[Fringe Benefits]{.underline}** (24%) \$15,360

> **Enter Fringe Benefits subtotal on 424A, Section B, 6.b. \$15,360**

**[Travel]{.underline}**

2 trips for SAMHSA Meetings for 2 Attendees

(Airfare @ \$600 x 4 = \$2,400) + (per diem

@ \$120 x 4 x 6 days = \$2,880) \$5,280

Local Travel (500 miles x .24 per mile) 120

\[Note: Current Federal Government per diem rates are available at
[www.gsa.gov](http://www.gsa.gov/).\]

> **Enter Travel subtotal on 424A, Section B, 6.c. \$ 5,400**

**[Equipment]{.underline}** (List Individually)

> \"Equipment\" means an article of nonexpendable, tangible personal
> property having a useful life of more than one year and an acquisition
> cost which equals the lesser of (a) the capitalization level
> established by the governmental unit or nongovernmental applicant for
> financial statement purposes, or (b) \$5000.

**Enter Equipment subtotal on 424A, Section B, 6.d.**

**[Supplies]{.underline}**

Office Supplies \$500

Computer Software - 1 WordPerfect 500

**Enter Supplies subtotal on 424A, Section B, 6.e. \$1,000**

LLUSTRATION OF DETAILED BUDGET AND NARRATIVE JUSTIFICATION (cont'd.)

**[Contractual Costs]{.underline}**

**Evaluation**

Job Name Annual Salary being Level of

Title Salary Requested Effort

Evaluator J. Wilson \$48,000 \$24,000 0.5

Other Staff \$18,000 \$18,000 1.0

Fringe Benefits (25%) \$10,500

**Travel**

2 trips x 1 Evaluator

(\$600 x 2) \$ 1,200

per diem @ \$120 x 6 720

Supplies (General Office) 500

Evaluation Direct \$54,920

Evaluation Indirect Costs (19%) \$10,435

Evaluation Subtotal \$65,355

**Training**

Job Name Level of Salary being

Title Effort Requested

Coordinator M. Smith 0.5 \$ 12,000

Admin. Asst. N. Jones 0.5 \$ 9,000

Fringe Benefits (25%) \$ 5,250

**Travel**

2 Trips for Training

Airfare @ \$600 x 2 \$ 1,200

Per Diem \$120 x 2 x 2 days 480

Local (500 miles x .24/mile) 120

**Supplies**

Office Supplies \$ 500

Software (WordPerfect) 500

**Other**

Rent (500 Sq. Ft. x \$9.95) \$ 4,975

Telephone 500

Maintenance (e.g., van) \$ 2,500

Audit \$ 3,000

Training Direct \$ 40,025

Training Indirect \$ -0-

**Enter Contractual subtotal on 424A, Section B, 6.f. \$105,380**

LLUSTRATION OF DETAILED BUDGET AND NARRATIVE JUSTIFICATION (cont'd.)

**[Other]{.underline}**

Consultants = Expert @ \$250/day X 6 day \$ 1,500

(If expert is known, should list by name)

**Enter Other subtotal on 424A, Section B, 6.h. \$ 1,500**

**Total Direct Charges (sum of 6.a-6.h)**

**Enter Total Direct on 424A, Section B, 6.i. \$192,640**

**[Indirect Costs]{.underline}**

15% of Salary and Wages (copy of negotiated

indirect cost rate agreement attached)

**Enter Indirect subtotal of 424A, Section B, 6.j. \$ 9,600**

**[TOTALS]{.underline}**

**Enter TOTAL on 424A, Section B, 6.k. \$202,240**

**[JUSTIFICATION]{.underline}**

PERSONNEL - Describe the role and responsibilities of each position.

FRINGE BENEFITS - List all components of the fringe benefit rate.

EQUIPMENT - List equipment and describe the need and the purpose of the
equipment in relation to the proposed project.

SUPPLIES - Generally self-explanatory; however, if not, describe need.
Include explanation of how the cost has been estimated.

TRAVEL - Explain need for all travel other than that required by SAMHSA.

CONTRACTUAL COSTS - Explain the need for each contractual arrangement
and how these components relate to the overall project.

OTHER - Generally self-explanatory. If consultants are included in this
category, explain the need and how the consultant's rate has been
determined.

INDIRECT COST RATE - If your organization has no indirect cost rate,
please indicate whether your organization plans to a) waive indirect
costs if an award is issued, or b) negotiate and establish an indirect
cost rate with DHHS within 90 days of award issuance.

[CALCULATION OF FUTURE BUDGET PERIODS]{.underline}

[(based on first 12-month budget period)]{.underline}

Review and verify the accuracy of future year budget estimates.
Increases or decreases in the future years must be explained and
justified and no cost of living increases will be honored. (NOTE: new
salary cap of \$180,100 is effective for all FY 2005 awards.) \*

First Second Third

12-month 12-month 12-month

Period Period Period

Personnel

Project Director 30,000 30,000 30,000

Secretary\*\* 9,000 18,000 18,000

Counselor 25,000 25,000 25,000

TOTAL PERSONNEL 64,000 73,000 73,000

\*Consistent with the requirement in the Consolidated Appropriations
Act, Public Law 108-447.

\*\*Increased from 50% to 100% effort in 02 through 03 budget periods.

Fringe Benefits (24%) 15,360 17,520 17,520

Travel 5,400 5,400 5,400

Equipment -0- -0- -0-

Supplies\*\*\* 1,000 520 520

\*\*\*Increased amount in 01 year represents costs for software.

Contractual

Evaluation\*\*\*\* 65,355 67,969 70,688

Training 40,025 40,025 40,025

\*\*\*\*Increased amounts in 02 and 03 years are reflected of the
increase in client data collection.

Other 1,500 1,500 1,500

Total Direct Costs 192,640 205,934 208,653

Indirect Costs 9,600 9,600 9,600

(15% S&W)

TOTAL COSTS 202,240 216,884 219,603

The Federal dollars requested for all object class categories for the
first 12-month budget period are entered on Form 424A, Section B, Column
(1), lines 6a-6i. The [total]{.underline} Federal dollars requested for
the second through the fifth 12-month budget periods are entered on Form
424A, Section E, Columns (b) -- (e), line 20. The RFA will specify the
maximum number of years of support that may be requested.

### Appendix E - Examples of State Specific Access and Retention Measures

**I. Access Measures: Timeliness to Treatment**

**Average Time to First Client Treatment Session** will measure the time
elapsed between the date a client first contacts the agency requesting
service and the date that the client received their first treatment
session, where a treatment session represents an individual or group
session. It will be calculated as follows:

+-----------------------------------------------------------------------+
| *[(Sum of the Date of Admission -- Date of 1^st^ Contact for all      |
| clients)]{.underline}*                                                |
|                                                                       |
| *(Number of Clients who receive a 1^st^ Treatment Session)*           |
+-----------------------------------------------------------------------+

**Average Time from the 1^st^ to the 2^nd^ Clinical Encounter** will
measure the time elapsed between the date a client first has a face to
face clinical encounter (e.g., assessment) to the second such face to
face clinical encounter. It will be calculated as follows:

+-----------------------------------------------------------------------+
| *[(Sum of the Date of 2^nd^ Clinical Encounter -- Date of 1^st^       |
| Clinical Encounter for all clients)]{.underline}*                     |
|                                                                       |
| *(Number of Clients who receive a 2^nd^ Clinical Encounter)*          |
+-----------------------------------------------------------------------+

**Average Time from First Clinical Encounter to Admission** will measure
the time elapsed between the date a client first has a face to face
clinical encounter (e.g., assessment) and the date that the client is
actually admitted to treatment at a specified ASAM level of care. It
will be calculated as follows:

+-----------------------------------------------------------------------+
| *[(Sum of the Date of Admission -- Date of 1^st^ Clinical Encounter   |
| for all clients)]{.underline}*                                        |
|                                                                       |
| *(Number of Clients who are admitted to a specified ASAM Level of     |
| Care)*                                                                |
+-----------------------------------------------------------------------+

**Retention Measures: Continuation in Treatment**

**Assessment Conversion Rate** will measure the number of 1^st^ request
for a clinical service that actually receives an assessment. It will be
calculated as follows:

+--------------------------------------------------------------+--------+
| *[(Number of Completed Outpatient Assessments)]{.underline}* | *X     |
|                                                              | 100*   |
| *(Number of 1^st^ Request for Outpatient Services)*          |        |
+--------------------------------------------------------------+--------+

**Admission Conversion Rate** will measure the number of clients who
receive an assessment who are actually admitted to receive ASAM Level of
Care I -- Outpatient Services. It will be calculated as follows:

+--------------------------------------------------------------+--------+
| *[(Number of Outpatient Admissions)]{.underline}*            | *X     |
|                                                              | 100*   |
| *(Number of Completed Outpatient Assessments)*               |        |
+--------------------------------------------------------------+--------+

**Early Client Engagement Rate** will measure the successful completion
of four group or individual sessions within thirty days of admission. It
will be calculated as follows:

+----------------------------------------------------------------+-----+
| *([\# of Clients who received 4 OP Treatment Sessions within   | *X  |
| 30 days of the 1^st^ Treatment Session)]{.underline}*          | 1   |
|                                                                | 00* |
| *(# of Clients Admitted to Outpatient Treatment)*              |     |
+----------------------------------------------------------------+-----+

### Appendix F - CSAT Core GPRA Client Outcome Tool

Number range CHAPTERForm Approved

OMB No. 0930-0208

Expiration Date 01/31/2007

**CSAT GPRA Client Outcome**

**Measures for Discretionary Programs**

**\[NOTE: This Appendix contains only Sections A, J, and K of CSAT's
GPRA Client Outcome Measures\]**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response if all items are asked of a
client/participant; to the extent that providers already obtain much of
this information as part of their ongoing client/participant intake or
followup, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information to
SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road,
Rockville, MD 20857. An agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it
displays a currently valid OMB control number. The control number for
this project is 0930-0208.

A. RECORD MANAGEMENT

**Client ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Client Type:**

-   Treatment client

-   Client in recovery

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

Interview Type *\[CIRCLE ONLY ONE TYPE.\]*

Intake \[GO TO INTERVIEW DATE\]

6 month follow-up **→ → →** Did you conduct a follow-up interview?
 Yes   No

***\[IF NO, GO DIRECTLY TO SECTION I.\]***

3 month follow-up ***\[ADOLESCENT PORTFOLIO ONLY\]* →**  

Did you conduct a follow-up interview?  Yes   No ***\[IF NO, GO DIRECTLY
TO SECTION I.\]***

Discharge **→ → →** Did you conduct a discharge interview?  Yes   No

***\[IF NO, GO DIRECTLY TO SECTION J.\]***

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

Month Day Year

*FOR SBIRT GRANTS ONLY: REPORTED ONLY AT INTAKE/BASELINE*

How did the client screen?   Negative   Positive

What was his/her screening score? AUDIT = \|\_\_\_\_\|\_\_\_\_\|

CAGE = \|\_\_\_\_\|\_\_\_\_\|

DAST = \|\_\_\_\_\|\_\_\_\_\|

DAST-10 = \|\_\_\_\_\|\_\_\_\_\|

NIAAA Guide = \|\_\_\_\_\|\_\_\_\_\|

Other (Specify) \_\_\_\_\_\_\_\_\_\_\_\_\_ = \|\_\_\_\_\|\_\_\_\_\|

Was he/she willing to continue his/her participation in the SBIRT
program?   Yes   No

*\[FOLLOW-UP AND DISCHARGE INTERVIEWS: SKIP TO SECTION B.\]*

A. RECORD MANAGEMENT (Continued)

PLANNED SERVICES \[*REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT
INTAKE/BASELINE\]*

**Identify the services you plan to provide to the client during the
client's course of treatment/recovery. *\[CIRCLE 'Y' FOR YES OR 'N' FOR
NO FOR EACH ONE.\]***

**Modality Yes No**

***\[SELECT AT LEAST ONE MODALITY.\]***

1\. Case Management Y N

2\. Day Treatment Y N

3\. Inpatient/Hospital (Other Than Detox) Y N

4\. Outpatient Y N

5\. Outreach Y N

6\. Intensive Outpatient Y N

7\. Methadone Y N

8\. Residential/Rehabilitation Y N

9\. Detoxification (Select Only One)

> A. Hospital Inpatient Y N
>
> B. Free Standing Residential Y N
>
> C. Ambulatory Detoxification Y N

10\. After Care Y N

11\. Recovery Support Y N

12\. Other (Specify) Y N

**Treatment Services Yes No**

***\[SBIRT GRANTS: You must circle 'Y' for at least one of the Treatment
Services numbered 1 through 4.\]***

1\. Screening Y N

2\. Brief Intervention Y N

3\. Brief Treatment Y N

4\. Referral to Treatment Y N

5\. Assessment Y N

6\. Treatment/Recovery Planning Y N

7\. Individual Counseling Y N

8\. Group Counseling Y N

9\. Family/Marriage Counseling Y N

10\. Co-Occurring Treatment/

‌Recovery Services Y N

11\. Pharmacological Interventions Y N

12\. HIV/AIDS Counseling Y N

13\. Other Clinical Services Y N

(Specify)

**Case Management Services Yes No**

1\. Family Services (Including Marriage Education, Parenting, Child
Development Services) Y N

2\. Child Care Y N

3\. Employment Service

> A. Pre-Employment Y N
>
> B. Employment Coaching Y N

4\. Individual Services Coordination Y N

5\. Transportation Y N

6\. HIV/AIDS Service Y N

7\. Supportive Transitional Drug-Free Housing Services Y N

8\. Other Case Management Services Y N

(Specify)

**Medical Services Yes No**

1\. Medical Care Y N

2\. Alcohol/Drug Testing Y N

3\. HIV/AIDS Medical Support & Testing Y N

4\. Other Medical Services Y N

(Specify)

**After Care Services Yes No**

1\. Continuing Care Y N

2\. Relapse Prevention Y N

3\. Recovery Coaching Y N

4\. Self-Help and Support Groups Y N

5\. Spiritual Support Y N

6\. Other After Care Services Y N

(Specify)

**Education Services Yes No**

1\. Substance Abuse Education Y N

2\. HIV/AIDS Education Y N

3\. Other Education Services Y N

(Specify)

**Peer-To-Peer Recovery Support Services Yes No**

1\. Peer Coaching or Mentoring Y N

2\. Housing Support Y N

3\. Alcohol- and Drug-Free Social Activities Y N

4\. Information and Referral Y N

5\. Other Peer-to-Peer Recovery Support Services Y N

(Specify)

A. RECORD MANAGEMENT - DEMOGRAPHICS *\[ASKED ONLY AT INTAKE/BASELINE\]*

**1. What is your gender?**

Male

Female

Transgender

Other (Specify)

Refused

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

Yes

No

Refused

***\[IF YES\]* What ethnic group do you consider yourself? Please answer
yes or no for each of the following. You may say yes to more than one.**

**Yes No Refused**

Central American Y N Refused

Cuban Y N Refused

Dominican Y N Refused

Mexican Y N Refused

Puerto Rican Y N Refused

South American Y N Refused

Other Y N Refused *\[IF YES, SPECIFY BELOW\]*

(Specify)

**3. What is your race? Please answer yes or no for each of the
following. You may say yes to more than one.**

**Yes No Refused**

Black or African American Y N Refused

Asian Y N Refused

Native Hawaiian or other Pacific Islander Y N Refused

Alaska Native Y N Refused

White Y N Refused

American Indian Y N Refused

**4. What is your date of birth?\***

\|\_\_\_\_\|\_\_\_\_\| / [\|\_\_\_\_\|\_\_\_\_\|]{.mark} /

Month Day

\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Year

 Refused

***\*The system will only save Month and Year**. DAY IS NOT SAVED TO
MAINTAIN CONFIDENTIALITY.*

J. DISCHARGE STATUS

*\[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE\]*

**1. On what date was the client discharged?**

\|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Month Day Year

**2. What is the client's discharge status?**

01 = Completion/Graduate

02 = Termination

If the client was terminated, what was the reason for termination?
\[*Select one response*.\]

01 = Left on own against staff advice with satisfactory progress

02 = Left on own against staff advice without satisfactory progress

03 = Involuntarily discharged due to nonparticipation

04 = Involuntarily discharged due to violation of rules

05 = Referred to another program or other services with satisfactory
progress

06 = Referred to another program or other services with unsatisfactory
progress

07 = Incarcerated due to offense committed while in treatment/recovery
with satisfactory progress

08 = Incarcerated due to offense committed while in treatment/recovery
with unsatisfactory progress

09 = Incarcerated due to old warrant or charged from before entering
treatment/recovery with satisfactory progress

10 = Incarcerated due to old warrant or charged from before entering
treatment/recovery with unsatisfactory progress

11 = Transferred to another facility for health reasons

12 = Death

13 = Other (Specify)

K. SERVICES RECEIVED

*\[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE\]*

**Identify the number of DAYS of services provided to the client during
the client's course of treatment**/‌**recovery. *\[ENTER ZERO IF NO
SERVICES PROVIDED. YOU SHOULD HAVE AT LEAST ONE DAY FOR MODALITY.\]***

**Modality Days**

1\. Case Management \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Day Treatment \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Inpatient/‌Hospital (Other Than Detox) \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Outpatient \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Outreach \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. Intensive Outpatient \|\_\_\_\|\_\_\_\|\_\_\_\|

7\. Methadone \|\_\_\_\|\_\_\_\|\_\_\_\|

8\. Residential/Rehabilitation \|\_\_\_\|\_\_\_\|\_\_\_\|

9\. Detoxification (Select Only One)

> A. Hospital Inpatient \|\_\_\_\|\_\_\_\|\_\_\_\|
>
> B. Free Standing Residential \|\_\_\_\|\_\_\_\|\_\_\_\|
>
> C. Ambulatory Detoxification \|\_\_\_\|\_\_\_\|\_\_\_\|

10\. After Care \|\_\_\_\|\_\_\_\|\_\_\_\|

11\. Recovery Support \|\_\_\_\|\_\_\_\|\_\_\_\|

12\. Other (Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Identify the number of SESSIONS provided to the client during the
client's course of treatment**/‌**recovery. *\[ENTER ZERO IF NO SERVICES
PROVIDED.\]***

**Treatment Services Sessions**

***\[SBIRT GRANTS: You must have at least one session for one of the
Treatment Services numbered 1 through 4.\]***

1\. Screening \|\_\_\_\|\_\_\_\|\_\_\_\|

2 Brief Intervention \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Brief Treatment \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Referral to Treatment \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Assessment \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. Treatment/Recovery Planning \|\_\_\_\|\_\_\_\|\_\_\_\|

7\. Individual Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

8\. Group Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

9\. Family/Marriage Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

10\. Co-Occurring Treatment/‌Recovery Services \|\_\_\_\|\_\_\_\|\_\_\_\|

11\. Pharmacological Interventions \|\_\_\_\|\_\_\_\|\_\_\_\|

12\. HIV/AIDS Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

13\. Other Clinical Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Case Management Services Sessions**

1\. Family Services (Including Marriage Education, Parenting, Child
Development Services) \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Child Care \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Employment Service

> A. Pre-Employment \|\_\_\_\|\_\_\_\|\_\_\_\|
>
> B. Employment Coaching \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Individual Services Coordination \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Transportation \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. HIV/AIDS Service \|\_\_\_\|\_\_\_\|\_\_\_\|

7\. Supportive Transitional Drug-Free Housing Services
\|\_\_\_\|\_\_\_\|\_\_\_\|

8\. Other Case Management Services (Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Medical Services Sessions**

1\. Medical Care \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Alcohol/Drug Testing \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. HIV/ AIDS Medical Support & Testing \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Other Medical Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**After Care Services Sessions**

1\. Continuing Care \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Relapse Prevention \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Recovery Coaching \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Self-Help and Support Groups \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Spiritual Support \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. Other After Care Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Education Services Sessions**

1\. Substance Abuse Education \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. HIV/AIDS Education \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Other Education Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Peer-To-Peer Recovery Support Services Sessions**

1\. Peer Coaching or Mentoring \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Housing Support \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Alcohol- and Drug-Free Social Activities \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Information and Referral \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Other Peer-to-Peer Recovery Support Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|