Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

**Access to Recovery (Short Title: ATR)**

**(Initial Announcement)**

**Request for Applications (RFA) No. TI-07-005**

**Catalogue of Federal Domestic Assistance (CFDA) No**.: 93.275

**Key Dates:**

  ----------------------- -----------------------------------------------
  **Application           **Applications are due by June 7, 2007.**
  Deadline**              

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

Number range CHAPTER

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

H. Westley Clark, M.D., J.D., M.P.H. Terry L. Cline, Ph.D.

Director Administrator

Center for Substance Abuse Treatment Substance Abuse and Mental Health

Substance Abuse and Mental Health Services Administration

Services Administration

**Table of Contents**

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

1\. INTRODUCTION [3](#introduction)

2\. EXPECTATIONS [3](#expectations)

II\. AWARD INFORMATION [3](#ii.-award-information)

1\. AWARD AMOUNT [3](#award-amount)

2\. FUNDING MECHANISM [3](#funding-mechanism)

3\. GRANTEE ADMINISTRATIVE COSTS [3](#grantee-administrative-costs)

III\. ELIGIBILITY INFORMATION [3](#iii.-eligibility-information)

1\. ELIGIBLE APPLICANTS [3](#eligible-applicants)

2\. COST SHARING [3](#cost-sharing)

3\. OTHER [3](#other)

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

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

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

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

4\. FUNDING LIMITATIONS/RESTRICTIONS
[3](#funding-limitationsrestrictions)

5\. OTHER SUBMISSION REQUIREMENTS [3](#other-submission-requirements)

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

1\. EVALUATION CRITERIA [3](#evaluation-criteria)

2\. REVIEW AND SELECTION PROCESS [3](#review-and-selection-process)

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

1\. AWARD NOTICES [3](#award-notices)

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

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

VII\. AGENCY CONTACTS [3](#vii.-agency-contacts)

Appendix A: Comprehensive Array of Clinical Treatment and Recovery
Support Services
[3](#appendix-a-comprehensive-number-range-chapterarray-of-clinical-treatment-and-recovery-support-services)

Appendix B: Services Included as Administrative Expenses
[3](#appendix-b-services-included-as-administrative-expenses)

Appendix C: Standards For The Access To Recovery (ATR) Program
[3](#appendix-cnumber-range-chapter-standards-for-the-access-to-recovery-atr-program)

Appendix D: Screening, Assessment, and Level of Care Determination
[3](#appendix-d-screening-assessment-and-level-of-care-determination)

Appendix E: Examples of How a State Could Implement a Voucher Program
[3](#appendix-e-examples-of-how-a-state-could-implement-a-voucher-program)

Appendix F: Checklist for Formatting Requirements and Screenout Criteria
for SAMHSA Grant Applications
[3](#appendix-f-checklist-for-formatting-requirements-and-screenout-criteria-for-samhsa-grant-applications)

Appendix G: Sample Budget and Justification
[3](#appendix-g-sample-budget-and-justification)

Appendix H: Managing On The Basis Of Reasonable Costs
[3](#appendix-h-managing-on-the-basis-of-reasonable-costs)

Appendix I: CSAT GPRA Client Outcome Measures for Discretionary Programs
[3](#appendix-i)

Appendix J: Voucher Information - Access to Recovery Program
[3](#appendix-j)

Appendix K: Voucher Transaction Information - Access to Recovery Program
[3](#appendix-k)

Appendix L: Confidentiality and Participant Protection
[3](#appendix-l-confidentiality-and-participant-protection)

Appendix M: Access to Recovery Performance Targets
[3](#appendix-m-access-to-recovery-performance-targets)

#   {#section .unnumbered}

# I. FUNDING OPPORTUNITY DESCRIPTION {#i.-funding-opportunity-description .unnumbered}

## 1. INTRODUCTION {#introduction .unnumbered}

###### []{.mark} {#section-1 .unnumbered}

The United States Department of Health and Human Services (HHS),
Substance Abuse and Mental Health Services Administration's (SAMHSA)
Center for Substance Abuse Treatment (CSAT) announces the availability
of fiscal year (FY) 2007 funds for Access to Recovery (ATR) grants. The
ATR grants provide funding to States, Tribes, and Tribal organizations
to carry-out voucher programs for substance abuse clinical treatment and
recovery support services pursuant to sections 501(d)(5) and 509 of the
Public Health Service Act (42 U.S.C. sections 290aa(d)(5) and 290bb-2).
This program addresses Healthy People 2010 focus area 26 (Substance
Abuse).

The Access to Recovery (ATR) Program is part of a Presidential
initiative to provide client choice among substance abuse clinical
treatment and recovery support service providers, expand access to a
comprehensive array of clinical treatment and recovery support options
(including faith-based programmatic options), and increase substance
abuse treatment capacity. Monitoring outcomes, tracking costs, and
preventing waste, fraud and abuse to ensure accountability and
effectiveness in the use of Federal funds are also important elements of
the ATR program. Through the ATR grants, States, Territories, the
District of Columbia, Tribes, and Tribal Organizations (hereinafter
collectively referred to as "States") will have flexibility in designing
and implementing voucher programs, consistent with proven models, to
meet the needs of clients in the State. The key to successful
implementation of the voucher programs supported by the ATR grants will
be the relationship between the States and clients receiving services,
to ensure that clients have a genuine, free, and independent choice
among eligible providers. States are encouraged to support a mixture of
clinical treatment and recovery support services that can be expected to
achieve the program's goal of achieving cost-effective, successful
outcomes for the largest number of people. Current ATR grantees as well
as entities meeting the eligibility criteria that have not received an
ATR grant may apply. See Section III-Eligibility Information for
additional information about eligibility for the ATR program.

There is a growing awareness of the devastating impact of
methamphetamine use on communities. Methamphetamine is a highly
addictive stimulant that can have serious effects on a user\'s physical,
mental, and social well-being. SAMHSA/CSAT is committed to reducing
methamphetamine use and is working toward a target of \$25 million per
year within the ATR program to address this problem. Accordingly, States
are encouraged to include vouchers for methamphetamine-related treatment
[and]{.underline} recovery support services within their proposed ATR
projects.

## 2. EXPECTATIONS {#expectations .unnumbered}

ATR grantees will be expected to use their ATR grant funds to facilitate
individual choice and promote multiple pathways to recovery through the
development and implementation of substance abuse treatment and recovery
support service voucher systems.

States should propose innovative strategies for their ATR projects to
accomplish the following:

-   Ensure genuine, free, and independent client choice for substance
    abuse clinical treatment and recovery support services appropriate
    to the level of care needed by the client. For the purposes of this
    grant program, choice is defined as a client being able to choose
    from among two or more providers qualified to render the services
    needed by the client, among them at least one provider to which the
    client has no religious objection.

-   Provide all substance abuse assessment, clinical treatment, and
    recovery support services funded through the ATR grant through
    vouchers given to a client by a State/Territory/Tribe or its
    designee. No funding shall be given directly to a provider through a
    grant or contract to provide any services under this program,
    including assessment.[^1]

-   Ensure each client receives an assessment for the appropriate level
    of services and is then provided a genuine, free, and independent
    choice among eligible providers, among them at least one provider to
    which the client has no religious objection.

-   Allow eligible clients to pay for assessment and other clinical
    treatment and recovery support services from a broad network of
    eligible providers, including organizations that have not previously
    received public funding. Eligible service providers for the voucher
    program may include the following: public and private, nonprofit,
    proprietary, as well as faith-based and community organizations, as
    approved through established procedures by the
    State/Territory/Tribe.

-   Ensure that faith-based organizations otherwise eligible to
    participate in this program are not discriminated against on the
    basis of their religious character or affiliation.

-   Maintain accountability by creating an incentive system for positive
    outcomes and taking active steps to prevent waste, fraud and abuse.

-   Expand clinical treatment and recovery support services by
    leveraging use of all Federal funds, preventing cost shifting, and
    ensuring that these funds are used to supplement and not supplant
    current funding for substance abuse clinical treatment and recovery
    support services in the State. \[Note: States must include a letter
    in Appendix 4 of the application certifying that they will not use
    ATR funds to supplant current funding if they receive an award.\]

In developing applications for the ATR program, applicants must
establish a three year numbers served goal for the program and identify
key milestones over the three year grant project that will result in
achievement of the three year goal. Applicants should be aware that
SAMHSA is seeking to serve 135,000 people over the three years of the
ATR program (25,000 in year 1; 55,000 in year 2; and 55,000 in year 3).
Grantees will be held accountable for meeting the milestones they have
identified in their applications and contributing to the overall target
for the ATR program. If a grantee fails to meet a milestone, future
funding may be delayed until the grantee provides evidence that the
milestone has been met.

SAMHSA is especially interested in ensuring that the voucher systems
supported through the ATR projects include the most cost effective mix
of clinical treatment [and]{.underline} recovery support services
necessary to achieve intended outcomes. Applicants must include both
types of services in their proposed projects and are encouraged to
devote substantial funds to recovery support services. Within the 2004
cohort of ATR grantees, 49% of funds spent on vouchers were allocated to
recovery support services. SAMHSA encourages ATR grantees to continue
strong support for recovery support services. In many cases, it will be
desirable to provide various components of the service continuum
simultaneously, with the emphasis changing throughout the clinical
treatment and recovery process. For example, in the earlier, acute phase
of clinical treatment, heavier emphasis may be placed on clinical
treatment services; the emphasis may switch toward recovery support as
individuals move through rehabilitation and enter a maintenance phase of
clinical treatment and recovery. In some cases, depending on the results
of the initial assessment, recovery support services alone will suffice.

SAMHSA is also interested in the use of voucher systems to support
methamphetamine-related treatment [and]{.underline} recovery support
services and is working toward a target of \$25 million per year within
the ATR program for this purpose. Accordingly, States are encouraged to
include vouchers for methamphetamine-related treatment [and]{.underline}
recovery support services within their proposed ATR projects. All
applicants will be required to discuss the need for
methamphetamine-related treatment and recovery support services in the
target population/community and to indicate whether and how their
proposed projects address the need for these services. Funded grantees
will be required to report performance, progress and financial
information for their projects as a whole as well as for their
methamphetamine-related activities.

SAMHSA is interested in supporting a range of models to implement
substance abuse voucher programs, including:

-   Full implementation of the program through a designated lead State
    or sub-State agency.

-   Implementation of the program through public/private partnerships
    (i.e., a contract between the State and a lead private entity to
    implement all or part of the program).

    States may implement the program Statewide or may target geographic
    areas of greatest need, specific populations in need, or
    areas/populations with a high degree of readiness to implement a
    voucher program. States may propose alternate models for
    consideration, as long as they conform to the expectations
    articulated above.

    States are encouraged to minimize the funds used to cover both the
    direct and indirect costs of administration of the program, to
    develop a system to manage the program on the basis of reasonable
    costs, to develop a system to provide incentives to eligible
    providers with superior outcomes, and to include a broad range of
    stakeholders in planning and designing their proposal.

    Appendix E of this announcement provides hypothetical examples of a
    program that conforms to these expectations. States may wish to
    consult this appendix as a starting point for developing their ATR
    Grant applications.

    Due to the unique nature of this grant program, SAMHSA recognizes
    that applicants may wish to entertain an array of program and
    administrative options. To respond, SAMHSA will make available both
    pre-application and post-award technical assistance to applicants
    and current and future providers of substance abuse clinical
    treatment and recovery support services under this program. Examples
    of topics for which technical assistance may be provided include,
    but are not limited to:

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-   Developing and maintaining a voucher system.

-   Eligibility determinations for clinical treatment and recovery
    support service providers and for which service in the continuum of
    recovery will be included in the voucher reimbursement system.

-   Eligibility determinations for clients, including management of a
    system for assessment and service determinations.

-   Identifying and determining eligibility of new clinical treatment
    and recovery support service providers.

-   Fiscal/cost accounting mechanisms that can track voucher
    implementation.

-   Management of information systems to track performance and outcomes.

-   Development of quality improvement activities, including technical
    assistance and training to attract, develop, and sustain new
    clinical treatment and recovery support service providers.

-   Oversight of standards and fraud and abuse.

-   Outreach to grass-roots community- and faith-based organizations and
    other entities unknown to the State.

-   Linkage to the criminal justice system including, but not limited
    to, State Departments of Corrections, probation, parole and jail
    authorities.

-   Linkage to housing programs and initiatives including, but not
    limited to, those supported with funding from State and local
    governments and the U.S. Department of Housing and Urban
    Development.

########  {#section-2 .unnumbered}

######## **2.1 Data and Performance Measurement**  {#data-and-performance-measurement .unnumbered}

The Government Performance and Results Act of 1993 (P.L.103-62, or
"GPRA") requires all Federal agencies to set program performance targets
and report annually on the degree to which the previous year's targets
were met.  Agencies are expected to evaluate their programs regularly
and to use results of these evaluations to explain their successes and
failures and justify requests for funding. SAMHSA has established the
performance targets for the ATR program. (See Appendix M of this RFA.)
The 2008-2010 targets are estimates based on past grantee performance.
These targets will be reviewed, and may be revised, based on information
provided in funded grantees' applications. Grantees will be expected to
contribute to achievement of these targets.

To meet the GPRA requirements, SAMHSA must collect performance data from
grantees.  ATR Grantees will be required to submit the performance data
described below to SAMHSA. Grantees must submit these data for the
program as a whole, as well as for the relevant methamphetamine-related
components of the program (e.g., the total number of people served and
the number of people receiving methamphetamine-related services; the
total number of vouchers issued and the number of vouchers issued for
methamphetamine-related services).  For the ATR program, SAMHSA will
assess program performance through accountability measures as well as
through outcome measures.  GPRA data must be collected in a face-to-face
interview at baseline (i.e., the client's entry into the project), six
months post baseline and at discharge (or exit from ATR services).
Grantees are also expected to submit voucher and transaction data via
the tool provided. Grantees will be required to obtain a minimum 80%
six-month follow-up rate.  GPRA data must be entered into the GPRA Data
Entry and Reporting System (www.samhsa-gpra.samhsa.gov) within 7
business days of the interview forms (intake and discharge) or
transaction forms being completed.  Grantees are expected to take action
necessary to ensure data are valid and reliable, and are submitted in a
timely manner. Data reporting is required to commence upon admission of
the first client.

[Accountability Measures]{.underline} 

SAMHSA will assess grantee performance using the following
accountability measures:[^2]

-   Target number of clients to be served

-   Number of vouchers issued and redeemed

-   Number of eligible clinical treatment providers -- total number of
    providers, providers identified as grass-roots providers, providers
    identified as faith-based and providers identified as secular

-   Number of eligible recovery support service providers -- total
    number of providers, providers identified as grass-roots providers,
    providers identified as faith-based and providers identified as
    secular

-   Clinical treatment services -- total clients served, clients served
    by grass-roots organizations, clients served by faith-based
    organizations and clients served by secular organizations

-   Recovery support services -- total clients served, clients served by
    grass-roots organizations, clients served by faith-based
    organizations and clients served by secular organizations

-   Combined services -- total clients served, clients served by
    grass-roots organizations, clients served by faith-based
    organizations, and clients served by secular organizations

-   Grant draw down

-   Expenditures for clinical treatment services -- total expenditures,
    clients served by grass-roots organizations, expenditures for
    services provided by faith-based organizations, and expenditures for
    services provided by secular organizations

-   Percentage of clients provided services directly referred from the
    criminal justice system including but not limited to prisons and
    jails.

-   Expenditures for recovery support services -- total expenditures,
    expenditures for grass-roots organizations, expenditures for
    faith-based organizations, and expenditures for secular
    organizations

-   Combined expenditures for clinical treatment and recovery support
    services -- total expenditures, expenditures for grass-roots
    organizations, expenditures for faith-based organizations, and
    expenditures for secular organizations

-   Administrative expenditures

Information should be provided on the type of service, date of service,
and the days, partial days, or hour(s) of service provided.  Each State
should submit data on reimbursement rate per service (clinical treatment
or recovery support service) per day, partial day, or hour(s) for the
voucher program.

[Outcome Measures]{.underline} 

SAMHSA will assess outcomes for the ATR program through the National
Outcome Measures (NOMs) for substance abuse treatment that SAMHSA has
developed in partnership with the States.  Grantees will be required to
report performance in several areas relating to the client's substance
use, family and living condition, employment status, social
connectedness, access to treatment, retention in treatment and criminal
justice status.  Grantees must collect and report data using the
Discretionary Services Client Level GPRA tool (Appendix I), which can be
found at
[www.samhsa-gpra.samhsa.gov](http://www.samhsa-gpra.samhsa.gov/) (click
on 'Data Collection Tools/Instructions'), along with instructions for
completing it. There are two other tools grantees are responsible to
report to CSAT: the voucher information tool and a voucher transaction
tool that are in Appendices J and K. Grantees use the voucher
information tool to report the amount for which the voucher was issued,
and the voucher transaction tool is used to report the amount for which
a specific provider redeemed the voucher. These two tools are used
primarily for tracking the status of each voucher that is issued to an
ATR client. It is important to note that these two tools are not asked
of the client. It is the responsibility of program staff to report this
programmatic information. Grantees can retain responsibility for
transmitting data submitted by providers to SAMHSA. However, grantees
(States/Tribes) can choose to allow providers to directly enter the
required data.

Outcome data must be collected at the time of entry to and at exit from
an episode of care and six months post entry.  (For the purposes of the
ATR program, an episode of care means the period of time from entry to
exit from a paid service, whether it be a clinical treatment service or
a recovery support service.)  In the case of brief interventions, only
drug/alcohol use should be reported.  In addition, rather than reporting
on retention for brief interventions, grantees should report on
completion.  Please note that the substance use domain is framed in
terms of rates of frequency of use; however, the primary outcome measure
for this program is abstinence from substance use, and successful
completion of an episode of care should be established by randomly
collected samples that are free of these substances.

Outcome data will be collected by individual service providers and given
to the grantees (i.e., States/Territories/Tribes).  In a situation where
a client is concurrently using multiple services, a single provider may
be delegated the responsibility to collect data on client outcomes. 
Grantees (i.e., States/Territories/Tribes) will be responsible for
transmitting the outcome data and other performance data to SAMHSA. 
Data will be submitted on an ongoing basis. As stated previously,
grantees (States/Territories/Tribes) can retain responsibility for
transmitting data submitted by providers to SAMHSA or they can choose to
allow providers to enter the required data directly.

Applicants are strongly encouraged to review the required data
collection forms in Appendices I, J and K of this grant announcement to
determine what changes, if any, will be necessary to the data
collection/management information systems within the
State/Territory/Tribe, so that these changes can be factored into the
proposed project.  For example, it will be necessary for States to
uniquely identify clients through the course of a clinical
treatment/recovery support episode of care and provide basic demographic
information.  Client IDs should be client specific and should also allow
for clients to be tracked though multiple episodes of care.

The terms and conditions of the ATR grant award will include these data
collection requirements.  Grantees will be required to adhere to these
terms and conditions.  Grantee ability to demonstrate improvement in the
above domains will be a factor in determining funding levels in years
after year 1 of the grant.  Grantees must propose a plan for collecting
6-month post-exit data from a paid service on a sample basis by the
third year of the grant.

Training and technical assistance on data collecting, tracking, and
follow-up, as well as data entry, will be provided by CSAT.

######## **Performance Assessment** 

Grantees must assess their projects, addressing the performance measures
described in Section I-2.1 (above). The assessment should be designed to
help you determine whether you are achieving the goals, objectives and
outcomes you intend to achieve and whether adjustments need to be made
to your project. You will be required to report on your progress
achieved, barriers encountered, and efforts to overcome these barriers
in a performance assessment report to be submitted at least annually.

In addition to assessing progress against the performance measures
required for this program, you may also want to consider outcome and
process questions, such as the following:

*Outcome Questions:*

-   What was the effect of intervention on participants?

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-   What program/contextual factors were associated with outcomes?

-   What individual factors were associated with outcomes?

-   How durable were the effects?

*Process Questions*:

-   How closely did implementation match the plan?

-   What types of deviation from the plan occurred?

-   What led to the deviations?

-   What effect did the deviations have on the planned intervention and
    performance assessment?

-   Who provided (program staff) what services (modality, type,
    intensity, duration), to whom (individual characteristics), in what
    context (system, community), and at what cost (facilities,
    personnel, dollars)?

Applicants should be aware that SAMHSA will be conducting a cross-site
evaluation of the ATR program. The evaluation will be designed to comply
with OMB expectations regarding independence, scope, and quality.
Grantees will be required to provide performance data to the evaluator
as well as to SAMHSA. In addition, it is possible the evaluation design
may necessitate changes in the required data elements and/or timing of
data collection or reporting. Grantees will be required to comply with
any changes in data collection requirements. SAMHSA will work in
collaboration with the States in developing any changes in data
collection requirements.

######## **2.3 Grantee Meetings** {#grantee-meetings .unnumbered}

Applicants must plan to send a minimum of three people (including the
Project Director) to at least one joint grantee meeting in 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 {#ii.-award-information .unnumbered}

## 1. AWARD AMOUNT {#award-amount .unnumbered}

It is expected that up to \$96 million will be available in fiscal year
2007 through Access to Recovery (ATR) to fund approximately 18 awards.
Applicants may request up to, but no more than, \$7,000,000 in total
costs (direct and indirect) per year in any year of the grant project.
Based on past experience, it is expected that grant awards will range
from \$1,000,000 to \$7,000,000 per year. Grants will be awarded for a
period of up to 3 years. The actual award amount in any one year will
depend on the availability of funds. Awards may be adjusted based on the
number of individuals proposed to be served per year and SAMHSA's
ability to reach the \$25 million target for methamphetamine-related
treatment and recovery support services. Applicants should be aware that
the amount to be awarded for continuation awards in year 3 is expected
to be 95% of the amount available awarded for continuation awards in
year 2. This is being done to create a pool of funds for supplemental
performance based awards (described below). \[Note: Applicants should
not reduce their requested third year amounts relative to year 2; this
adjustment will be made by SAMHSA at the time the year 3 continuation
awards are negotiated.\]

**Proposed budgets cannot exceed \$7,000,000 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, timely
submission of required data and reports, and grant expenditures.

**Supplemental Awards Based on Performance:** Section VI-2,
Administrative and National Policy Requirements, of this RFA discusses a
grantee\'s proposed performance targets and explains that failure to
meet stated goals and objectives may result in suspension or termination
of the grant award, or in the reduction or withholding of continuation
awards. Conversely, an ATR grantee that exceeds its performance targets
or demonstrates efficiencies may receive a supplemental award based on
performance to maintain its high level of performance.

For year 3 of the ATR grant program, CSAT will review each grantee\'s
Government Performance and Results Act (GPRA) data submissions and
assess whether a grantee has: 1) met or exceeded its target for the
number of clients served by 25 percent or more, 2) met or exceeded its
target for 6-month follow-ups[^3], and 3) provided services within
approved cost-bands. Any grantee that has demonstrated appropriate
financial management of the grant and has exceeded its targets for the
number of clients served by 25 percent or more, exceeded its target for
6-month follow-ups, and provided services within allowable cost bands,
may receive a supplemental award of up to 5 percent of the third year
requested amount based on performance. Supplemental award amounts will
be determined on a sliding scale based on availability of funds and the
grantee's achievement of performance goals and demonstration of sound
fiscal management. **Applicants should be aware that SAMHSA/CSAT does
not plan to make supplemental awards to all grantees, and that it is
possible that no grantees will receive supplemental awards based on
performance.**

Eligible grantees will be asked to submit a narrative and budget
justification for the supplemental award that maintains the increase in
its targets during the final year of the project. The supplemental award
based on performance is for the purpose of the grantee maintaining, at a
minimum, the additional number of clients for the remainder the project.

A grantee receiving a supplemental award based on performance may be
subject to additional site visits and/or audits to verify the accuracy
of the client data reported.

## 2. FUNDING MECHANISM {#funding-mechanism .unnumbered}

Awards will be made as grants to States that, in turn, must distribute
funds to clients through vouchers.

## 3. GRANTEE ADMINISTRATIVE COSTS {#grantee-administrative-costs .unnumbered}

A list of services considered to be administrative costs is contained in
Appendix B of this RFA. The direct and indirect costs of administration
of the program are to include the management of information systems for
tracking outcomes and costs, including the cost of data collection and
reporting. These are to be held to as low a percentage of the total
grant expenditures as possible. For new grantees, administrative costs
are not to exceed 15% of the total grant expenditures over the
three-year grant period. However, the percentage for the first year may
exceed 15% to cover startup expenditures for such activities as
establishing new voucher systems, provider networks, and State standards
for recovery support services, as long as the 15% average is maintained
over the life of the grant.

Current ATR grantees with established voucher and administrative systems
are expected to demonstrate improved efficiencies over the course of the
grant. Current ATR grantees proposing to continue services in the same
geographic areas and/or populations, should set a target for
administrative costs of 10% of the total grant expenditures annually.
The percentage of administrative costs for current grantees that
successfully compete for a new award will be negotiated between 10-15%,
depending on the justification and rationale for exceeding the 10%
target for administrative expenses. For example, administrative expenses
may need to be greater than 10% for current grantees proposing to expand
services in order to cover such startup costs as:

-   Establishing a voucher system in new areas;

-   Establishing an ATR provider network in areas where it does not now
    exist; and

-   Establishing and implementing data collection and tracking systems
    in new areas.

# III. ELIGIBILITY INFORMATION {#iii.-eligibility-information .unnumbered}

## ELIGIBLE APPLICANTS

Eligibility for ATR grants is limited to the immediate office of the
Chief Executive (e.g., Governor) in the States, Territories, District of
Columbia; or the highest ranking official and/or the duly authorized
official of a federally recognized American Indian/Alaska Native Tribe
or Tribal Organization. Tribal Organization means the recognized
governing body of any American Indian/Alaska Native tribe; any legally
established organization of American Indians/Alaska Natives 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 American Indians/Alaska Natives in all phases of its
activities. **The Chief Executive of the State, Territory, or District
of Columbia, or the highest ranking official and/or the duly authorized
official of the Tribe/Tribal Organization must sign the
application.**[^4]

Eligibility is limited to these applicants because only they have the
authority to coordinate funding across the State/Tribe, implement the
necessary policy changes, manage the fiscal responsibilities, and
coordinate the range of programs necessary for successful implementation
of the voucher programs to be funded through these grants.

No more than one ATR application from any one Chief Executive or head of
a Tribe/Tribal Organization will be funded.

Current ATR grantees are eligible to apply for an ATR grant in 2007.

## 2. COST SHARING  {#cost-sharing .unnumbered}

Cost sharing is not required in this program. However, grantees must use
these funds to supplement, and not supplant, current funding for
substance abuse clinical treatment and recovery support services and
maximize existing resources.

## 3. OTHER {#other .unnumbered}

########  {#section-3 .unnumbered}

######## **3.1 Additional Eligibility Requirements** {#additional-eligibility-requirements .unnumbered}

**You must comply with the following requirements, or your application
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 Appendix F of this
document.

# IV. APPLICATION AND SUBMISSION INFORMATION  {#iv.-application-and-submission-information .unnumbered}

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

## 1. ADDRESS TO REQUEST APPLICATION PACKAGE  {#address-to-request-application-package .unnumbered}

You may request a complete application kit from the SAMHSA Information
Line at 1-877-SAMHSA7 \[TDD: 1-800-487-4889\].

You also may download the required documents from the SAMHSA Web site at
<http://www.samhsa.gov/grants/apply.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

-   a list of certifications and assurances referenced in item 21 of the
    (SF) 424 v2.

## 2. CONTENT AND FORM OF APPLICATION SUBMISSION {#content-and-form-of-application-submission .unnumbered}

######## **2.1 Application Kit** {#application-kit .unnumbered}

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.**

-   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
    (<http://www.samhsa.gov/Grants/2007/fy2007.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** {#required-application-components .unnumbered}

Applications 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 v2, 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. It should include the project name, population to be served
    (demographics and clinical characteristics),
    strategies/interventions, project goals and measurable objectives,
    including the number of people to be served annually and throughout
    the lifetime of the project, etc. 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 PHS 5161-1.
    Fill out Sections B, C, and E of the SF 424A. A sample budget and
    justification is included in Appendix G of this document.

-   **Project Narrative and Supporting Documentation** -- The Project
    Narrative describes your project. It consists of Sections A
    through E. Sections A-E 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-1 -- 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 F through I. There are no page limits for these sections,
> except for Section H, Biographical Sketches/Job Descriptions.
> Additional instructions for completing these sections are included in
> Section V under "Supporting Documentation."

####### Appendices 1 through 5 --Use only the appendices listed below. If your application includes any appendices not required in this document, they will be disregarded. Do not use more than 30 pages for Appendices 1, 3, and 4 combined. There are no page limitations for Appendices 2 and 5. 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

-   *Appendix 2*: Data Collection Instruments/Interview Protocols

-   *Appendix 3*: Sample Consent Forms

-   *Appendix 4*: Non Supplantation letter

-   *Appendix 5*: Implementation Plan

    -   **Assurances** -- Non-Construction Programs. Use Standard Form
        424B found in PHS 5161-1. You are also required to complete the
        Assurance of Compliance with SAMHSA Charitable Choice Statutes
        and Regulations Form SMA 170. This form will be posted on
        SAMHSA's web site with the RFA and provided in the application
        kits.

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

-   **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** {#application-formatting-requirements .unnumbered}

**Please refer to Appendix F, *Checklist for Formatting Requirements and
Screenout Criteria for SAMHSA Grant Applications*, for SAMHSA's basic
application formatting requirements. Applications that do not comply
with these requirements will be screened out and will not be reviewed.**

## 3. SUBMISSION DATES AND TIMES  {#submission-dates-and-times .unnumbered}

Applications are due by close of business on **June 7, 2007**. **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.

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

If you would like to submit your application electronically, you may
search [www.Grants.gov](http://www.Grants.gov/) 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 Help page.
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, excluding Federal holidays.

**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: 1) DUNS Number registration; 2)
Central Contractor Registry (CCR) registration; 3) Credential Provider
registration; and 4) 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 PDF files. 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 in Appendix F 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 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 F,
    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 above. 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. Receipt of the tracking number is the only
indication that Grants.gov has successfully received and validated your
application. If you do not receive a Grants.gov tracking number, you may
want to contact the Grants.gov help desk for assistance.**

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 v2), the assurances (SF 424B), 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 services, change the zip code to 20850.**

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

## 4. FUNDING LIMITATIONS/RESTRICTIONS {#funding-limitationsrestrictions .unnumbered}

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

ATR grant funds must be used for purposes supported by the program and
may not be used to:

-   Pay for any lease beyond the project period.

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-   Provide services to incarcerated populations (defined as those
    persons in jail, prison, detention facilities, or in custody where
    they are not free to move about in the community).

-   Pay for the purchase or construction of any building or structure to
    house any part of the program. (Applicants may request up to
    \$75,000 for renovations and alterations of existing facilities, if
    necessary and appropriate to the project.)

-   Provide residential or outpatient treatment services when the
    facility has not yet been acquired, sited, approved, and met all
    requirements for human habitation and services provision. (Expansion
    or enhancement of existing residential services is permissible.)

-   Pay for housing other than residential mental health and/or
    substance abuse treatment.

-   Provide inpatient treatment or hospital-based detoxification
    services. Residential services are not considered to be inpatient or
    hospital-based services.

-   Pay for incentives to induce individuals to enter treatment.
    However, a grantee or treatment provider may provide up to \$20 or
    equivalent (coupons, bus tokens, gifts, child care, and vouchers) to
    individuals as incentives to participate in required data collection
    follow-up. This amount may be paid for participation in each
    required interview.

-   Implement syringe exchange programs, such as the purchase and
    distribution of syringes and/or needles.

-   Pay for pharmacologies for HIV antiretroviral therapy, sexually
    transmitted diseases (STD)/sexually transmitted illnesses (STI), TB,
    and hepatitis B and C, or for psychotropic drugs.

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

## 5. OTHER SUBMISSION REQUIREMENTS {#other-submission-requirements .unnumbered}

You may submit your application in either electronic or paper format:

[Submission of Electronic Applications]{.underline}

SAMHSA is collaborating with [www.Grants.gov](http://www.Grants.gov/) to
accept electronic submission of applications. 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.

**Please refer to Section IV-3 above for detailed instructions on
submitting your application electronically.**

[Submission of Paper Applications]{.underline}

You must submit an original application and 2 copies (including
appendices). The original and copies must not be bound. Do not use
staples, paper clips, or fasteners. Nothing should be attached, stapled,
folded, or pasted.

Send applications to the address below:

**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**

Change the zip code to **20850** if you are using another delivery
service.

Do not send applications to other agency contacts, as this could delay
receipt. Be sure to include the title of this program **(ATR Program)**
and the funding announcement number (**TI-07-005)** in item number 12 on
the face page of any paper applications:

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

**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 {#v.-application-review-information .unnumbered}

## EVALUATION CRITERIA 

Your application will be reviewed and scored according to the
[quality]{.underline} of your responses to the requirements listed below
for developing the Project Narrative (Sections A-E). These sections
describe what you intend to do with the 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-E) together may not be longer
        than 30 pages.

-   You must use the five sections/headings listed below in developing
    your Project Narrative(s). 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(s).

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-   Reviewers will be looking for evidence of cultural competence in
    each section of the Project Narrative. Points will be assigned based
    on how well you address the cultural competence aspects of the
    evaluation criteria. SAMHSA's guidelines for cultural competence can
    be found on the SAMHSA web site at
    [www.samhsa.gov](http://www.samhsa.gov/). Click on "Grants/Applying
    for a New SAMHSA Grant/Guidelines for Assessing Cultural
    Competence."

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-   The Supporting Documentation you provide in Sections F-I and
    Appendices 1-5 will be considered by reviewers in assessing your
    response, along with the material in the Project Narrative.

-   The number of points after each heading 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 the criterion.

**Project Narrative**

**Section A: Statement of Need (15 points)**

-   Describe the current substance abuse clinical treatment system in
    the proposed target area (i.e., the State, Territory or Tribe, or
    subsection of the State, Territory or Tribe). Include the number of
    clinical treatment providers currently funded by the
    State/Territory/Tribal Organization, gaps in service delivery, and
    barriers to service access.

-   Describe the current recovery support service system in the proposed
    target area. Include the number of recovery support services
    providers currently funded by the State/Territory/Tribal
    Organization, gaps in service delivery, and barriers to service
    access.

-   Describe the nature and prevalence of substance abuse problems in
    the target area, including that of persons returning to the target
    area following incarceration. Quantify the need for services,
    capacity of the service system to provide services, and the
    difference between the two.

-   Specifically describe the nature and prevalence of problems related
    to methamphetamine use in the target area. Quantify the need for
    methamphetamine-related treatment and recover support services, the
    capacity of the service system to provide these services, and the
    difference between the two.

-   Explicitly state whether or not the State, Territory or Tribal
    Organization already has a voucher system in place to pay for
    substance abuse treatment [and]{.underline} recovery support
    services. Discuss how the proposed project would help address the
    difference between system capacity and service need, including how
    and by how much capacity would be increased for each year of the
    grant. Clearly state the number of clients who would be served under
    the proposed project in each year of the grant. Clearly state the
    number of clients requiring methamphetamine-related treatment and/or
    recovery support services who would be served under the proposed
    project in each year of the grant.

    **Section B: Project Plans to Meet Original ATR Program Goals (30
    points)**

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-   Provide evidence that voucher recipients will have a genuine, free,
    and independent choice among eligible clinical treatment
    [and]{.underline} recovery support service options. Evidence is
    defined as at least 2 providers for each service to be provided
    using vouchers, one of which must be secular.

-   Describe the process to enable clinical treatment providers
    previously unable to compete effectively for Federal funds to
    participate in the voucher program (including faith-based and
    community providers). Describe the process to enable recovery
    support service providers previously unable to compete effectively
    for Federal funds to participate in the voucher program (including
    faith-based and community providers). Clearly state how many of such
    clinical treatment [and]{.underline} recovery support service
    providers are expected to be designated under this program and the
    timeframe in which this will occur. Affirm that faith-based
    organizations that otherwise satisfy program requirements will not
    be discriminated against on the basis of religious character or
    affiliation.

-   Provide plans for increasing capacity over the period of the voucher
    program, particularly for recovery support services.

-   Provide plans for monitoring the operation and the effectiveness of
    the voucher program jurisdiction through the timely reporting of
    data.

    **Section C: Proposed Approach (20 points)**

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-   Clearly state the three year goal of your proposed project. Describe
    how achievement of the three year goal will increase client choice
    with regard to services and increase access to/availability of
    prevention, outreach, pre-treatment, treatment, and recovery support
    services. Clearly indicate whether the proposed project will address
    methamphetamine use and, if so, how methamphetamine use will be
    incorporated into the goals for the project. For applicants that
    have already received ATR grants, indicate whether the proposed
    project differs in scope from the previous project and describe the
    differences, if appropriate. Applicants that have already received
    ATR grants should also discuss how the proposed project will build
    upon the lessons learned through the previous ATR grant.

-   Describe the approach that will be used to implement or expand
    (depending on applicant level of readiness) vouchers to pay for
    substance abuse treatment [and]{.underline} recovery support
    services (including methamphetamine-related treatment and recovery
    support services, if appropriate) in the State, Territory or Tribe.
    If you are a previous ATR grantee, you must discuss how the current
    program will be expanded under this grant. You must also document
    that the current program will be maintained. Include the following:

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-   Implementation model (e.g., State, sub-State agency including State
    Departments of Corrections and Probation and Parole authorities,
    public/private partnership or other model).

-   Infrastructure enhancements needed to accelerate implementation of
    vouchers, if the State/Territory/Tribal Organization does not
    already have a voucher system in place.

-   Eligibility criteria for clients to receive vouchers for clinical
    treatment and recovery support services. Clearly state the number of
    clients who would be successfully treated under the proposed
    program.

-   Procedures/policies for screening, assessment, and level of care
    determinations to identify appropriate clinical treatment
    [and]{.underline} recovery support services options and to place
    clients with the eligible provider of their choice.

-   Process to ensure that clients receive a comprehensive assessment,
    using an instrument that assesses need for clinical treatment
    [and]{.underline} recovery support services (See Appendix A for a
    discussion of clinical treatment and recovery support services, and
    Appendix D for information on screening, assessment, and level of
    care determination).

-   Process to ensure that clients receive vouchers for the most
    appropriate services and are transitioned between services based on
    established criteria. (See Appendices C and D for more information
    and resources about criteria.)

-   Steps to ensure that clients successfully enter clinical treatment
    and/or recovery support services following receipt of a voucher,
    regardless of where the client is seen for screening, assessment,
    and referral.

-   Eligibility criteria for provider organizations, including: (1)
    standards for all eligible provider organizations and/or processes
    to ensure individuals receive appropriate services in safe settings
    from appropriate individuals, including plans to enforce those
    standards and processes; and (2) reporting requirements. (See
    Appendix C for SAMHSA's expectations regarding standards for
    States.)

-   Method/process for designating providers as eligible participants in
    the voucher program and for maintaining an up-to-date, client
    friendly information service to ensure client choice is always
    available and clients are aware of their choices (e.g., a website or
    24-hour staffed help line).

-   Method/process for measuring client satisfaction in management of
    the voucher program.

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-   Unbundling of services, if the State intends to use this strategy to
    achieve the best outcomes at the lowest cost.

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-   Provide a three-year plan for implementing the project in Appendix 5
    of the application. The plan must include specific milestones with
    target dates for their achievement and must identify the party(ies)
    responsible for achieving milestones.

    **Section D: Readiness to Implement/Expand the Voucher System (15
    points)**

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-   Describe the timeframe by which the proposed voucher system would be
    fully operational (for applicants proposing new voucher systems) or
    expanded (for applicants proposing to expand an existing system).

    -   Document which of the following capabilities the State
        **[currently possesses]{.underline}** to implement or expand the
        voucher system:

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-   Ability to make eligibility determinations for clients and
    providers.

-   Ability to manage and monitor a voucher program.

-   Ability to set reimbursement rates and monitor costs per person
    served.

-   Ability to collect and report data (either through an existing or
    planned system).

-   Ability to implement quality improvement activities including
    technical assistance and training.

-   Ability to establish and implement standards for clinical treatment
    and/or recovery support service providers.

-   Capability to conduct screening and assessment and issue vouchers
    for clinical treatment and recovery support services based on
    established criteria.

-   Capability to provide a list of eligible providers for anyone to
    whom a voucher is issued.

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-   Describe anticipated potential operational problems, if any, and
    propose feasible solutions to them. Examples include:

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-   Ensuring clients genuine, free, and independent choice of clinical
    treatment and/or recovery support providers in situations in which
    the range and number of providers are limited.

-   Handling significant numbers of clients eligible for vouchers who
    may exceed the State's ability to fund vouchers, and ensuring that
    resources are appropriately allocated during the course of the year.

-   Preventing potential conflict-of-interest among those conducting
    screening, assessment, level of care determination, and service
    provision.

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-   Describe other organizations/entities partnering in the project,
    including their roles in implementing the voucher program. In
    Appendix 1 of the application, provide letters of commitment showing
    that identified partner organizations are ready and able to fulfill
    their roles.

    **Section E: Management, Staffing and Cost Controls (20 points)**

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-   Describe how the lead agency will manage the voucher program,
    including steps that will be taken to ensure quality of care;
    prevent waste, fraud and abuse; and prevent supplantation of funds.

-   Describe the resources available for the project. Document that
    resources will be appropriately allocated throughout the project
    period to ensure against funding shortfalls.

-   If you previously received an ATR grant, discuss how the proposed
    project will achieve improved efficiencies over the course of the
    project.

-   Describe how the lead agency will work with other agencies with
    roles and responsibilities related to identifying clients and
    implementing and administering the voucher program.

-   Describe how the provider performance issues will be addressed
    through the process of determining provider eligibility and through
    monitoring/oversight.

-   Describe the State's and other participating entities' experience
    managing other voucher-type programs (e.g., Temporary Assistance for
    Needy Families (TANF), HUD/housing, daycare), if any, and discuss
    how these experiences will be applied to the proposed voucher
    program.

-   Describe qualifications of the key staff to effectively implement
    and manage the proposed project.

-   Document the ability or present a plan for developing the ability of
    the State/Territory/Tribal Organization to collect and report all
    necessary GPRA data, including data on costs and outcomes, to
    SAMHSA.

-   Describe the process the State will use to regularly monitor
    implementation of the voucher program (including costs and outcomes)
    and make adjustments to the program (including the introduction of
    evidence-based practices) in order to achieve the intended outcomes
    in the most cost-effective manner. Specify how the State will create
    incentives for positive outcomes (e.g., adjusting provider
    eligibility reimbursement based on such outcomes). The extent to
    which evidence supports abstinence from substance use is of the
    utmost importance in assessing provider performance.

-   Describe the process for establishing reimbursement rates for
    services provided through vouchers.

-   Describe how the State will manage the program on the basis of
    reasonable costs. Include a justification if the applicant proposes
    to deviate from the cost ranges outlined in Appendix H.

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

**Section G:** 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.

    -   You must identify administrative expenses and justify the
        percent of the budget that will be allocated to administrative
        expenses.

    -   [If your project will include methamphetamine-related treatment
        and recovery support services, you must identify and justify the
        expenses associated with those services.]{.underline}

-   You should justify your proposed budget on the basis of a variety of
    factors, including specification of the direct and indirect costs of
    the project and the relationship of those costs to the number of
    people to be served, the number of to be issued, the size and
    complexity of the service delivery system to be converted to a
    voucher program, and the nature of the barriers which must be
    addressed in order to successfully implement a voucher program.

-   You should be mindful of the need to demonstrate that the proposed
    project will implement the most cost effective mix of clinical
    treatment and recovery support services necessary to achieve the
    intended outcomes of the project.

-   An illustration of a budget and narrative justification is included
    in Appendix G of this document.

####### Section H: Biographical Sketches and Job Descriptions.  {#section-h-biographical-sketches-and-job-descriptions. .unnumbered}

#######  {#section-4 .unnumbered}

####### 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 a letter of commitment with a current biographical sketch from the individual.

#######  {#section-5 .unnumbered}

####### 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).

    **Section I:** Confidentiality and SAMHSA Participant
    Protection/Human Subjects: Applicants must describe procedures
    relating to Confidentiality, Participant Protection and the
    Protection of Human Subjects Regulations in Section I of the
    application, using the guidelines provided below and in Appendix L
    of this document. Number range CHAPTER

    *[Confidentiality and Participant Protection]{.underline}***:**

Because of the confidential nature of the work in which many SAMHSA
grantees are involved, it is important to have safeguards protecting
individuals from risks associated with their participation in SAMHSA
projects. All applicants must address the eight bullets below. If some
are not applicable or relevant to the proposed project, simply state
that they are not applicable and indicate why. In addition to addressing
these eight bullets, read the section that follows entitled Protection
of Human Subjects Regulations to determine if the regulations may apply
to your project. If so, you are required to describe the process you
will follow for obtaining Institutional Review Board (IRB) approval.
While we encourage you to keep your responses brief, there are no page
limits for this section and no points will be assigned by the Review
Committee. Problems with confidentiality, participant protection, and
the protection of human subjects identified during peer review of the
application may result in the delay of funding.

-   Identify foreseeable risks or adverse effects due to participation
    in the project and/or in the data collection (performance
    assessment) activities (including physical, medical, psychological,
    social, legal, and confidentiality) and provide your procedures for
    minimizing or protecting participants from these risks.

-   Identify plans to provide guidance and assistance in the event there
    are adverse effects to participants.

-   Describe the target population and explain why you are including or
    excluding certain subgroups. Explain how and who will recruit and
    select participants.

-   State whether participation in the project is voluntary or required.
    If you plan to provide incentives/compensate victims, specify the
    type (e.g., money, gifts, coupons), and the value of any such
    incentives.

-   Describe data collection procedures, including sources (e.g.,
    participants, school records) and the data collecting setting (e.g.,
    clinic, school). Provide copies of proposed data collection
    instruments and interview protocols in **Appendix 2** of your
    application, "Data Collection Instruments/Interview Protocols."
    State whether specimens such as urine and/or blood will be obtained
    and the purpose for collecting. If applicable, describe how the
    specimens and process will be monitored to ensure the safety of
    participants.

-   Explain how you will ensure privacy and confidentiality of
    participants' records, data collected, interviews, and group
    discussions. Describe where the data will be stored, safeguards
    (e.g., locked, coding systems, storing identifiers separate from
    data), and who will have access to the information.

-   Describe the process for obtaining and documenting consent from
    adult participants and assent from minors along with consent from
    their parents or legal guardians. Provide copies of all consent
    forms in **Appendix 3** of your application, "Sample Consent Forms."
    If needed, give English translations.

-   Discuss why the risks are reasonable compared to expected benefits
    from the project.

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

    SAMHSA expects that most grantees funded under this announcement
    will not have to comply with the Protection of Human Subjects
    Regulations (45 CFR 46), which requires Institutional Review Board
    (IRB) approval. However, in some instances, the applicant's proposed
    performance assessment design may meet the regulation's criteria of
    research involving human subjects. Applicants whose projects must
    comply with the Human Subjects Regulations must, in addition to the
    bullets above, fully describe the process for obtaining IRB
    approval. While IRB approval is not required at the time of grant
    award, these grantees will be required, as a condition of award, to
    provide documentation that an Assurance of Compliance is on file
    with the Office for Human Research Protections (OHRP). IRB approval
    must be received in these cases prior to enrolling clients in the
    project. General information about Human Subjects Regulations can be
    obtained through OHRP at http://www.hhs.gov/ohrp, or
    ohrp@osophs.dhhs.gov, or (240) 453-6900. SAMHSA--specific questions
    should be directed to the program contact listed in Section VII of
    this announcement.

## 2. REVIEW AND SELECTION PROCESS {#review-and-selection-process .unnumbered}

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

-   availability of funds;

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

-   ability to reach the \$25 million target for methamphetamine-related
    treatment and recovery support services.

# VI. AWARD ADMINISTRATION INFORMATION {#vi.-award-administration-information .unnumbered}

## 1. AWARD NOTICES  {#award-notices .unnumbered}

#######  {#section-6 .unnumbered}

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  {#administrative-and-national-policy-requirements .unnumbered}

[]{.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:

    -   actions required to be in compliance with confidentiality and
        participant protection/human subjects requirements;

    -   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.

#######  {#section-7 .unnumbered}

## 3. REPORTING REQUIREMENTS {#reporting-requirements .unnumbered}

######## **3.1 Progress and Financial Reports** {#progress-and-financial-reports .unnumbered}

-   Grantees must submit required financial information and information
    not included in GPRA data on a monthly basis. The GPRA data will be
    submitted on an ongoing basis. Additionally, grantees are
    responsible for quarterly progress reporting to grants management. 

-   The monthly progress reports must include the performance data
    described in Section I-2.1 of this announcement, as well as
    information about fraud and abuse monitoring and examples of client
    success, until the grantee develops the capability to upload data
    through CSAT's GPRA Data Entry and Reporting System
    ([www.samhsa-gpra.samhsa.gov](http://www.samhsa-gpra.samhsa.gov/)). 
    After that time, the monthly progress reports will include only the
    performance information not captured in the GPRA Data Entry and
    Reporting System (e.g., information about fraud and abuse monitoring
    and examples of client success). 

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-   Because SAMHSA is extremely interested in ensuring that treatment
    and prevention services can be sustained, your progress reports
    should explain plans to ensure the sustainability 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 Publications**  {#publications .unnumbered}

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 grant
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.

#  {#section-8 .unnumbered}

# VII. AGENCY CONTACTS {#vii.-agency-contacts .unnumbered}

For questions about program issues contact:

Andrea Kopstein

Practice Improvement Branch, Division of Service Improvement

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Rd., Room 5-1095

Rockville, MD 20857

\(240\) 276-1575

<andrea.kopstein@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: Comprehensive Number range CHAPTERArray of Clinical Treatment and Recovery Support Services

Number range CHAPTER[Overview]{.underline}:

Number range CHAPTERResearch has established that there are many paths
to recovery from alcohol and drug problems. Indeed, many resolve their
alcohol and drug problems naturally, without any outside intervention.
Others recover with the support of self-help groups such as Alcoholics
Anonymous, and/or the faith community. Still others have found recovery
through formal clinical treatment interventions. A variety of factors
can influence which of these paths is taken successfully. For example,
individuals with moderate problems and social support/stability are more
apt to recover naturally or with minimal interventions. In contrast,
people who seek treatment tend to have more serious problems.

To achieve the best outcomes at the lowest cost, SAMHSA encourages
States to provide access to a comprehensive array of clinical treatment
and recovery support services as described below. Both components --
clinical treatment services and recovery support services--are
appropriate for many, if not all, individuals who meet the DSM-IV
diagnostic criteria for substance dependence. However, not all services
and/or interventions are needed by every individual in treatment for or
in recovery from substance dependence. Those who meet the diagnostic
criteria for substance abuse may require a less comprehensive range of
services. In addition, the array of services described below need not be
provided by a single entity but can be provided by a consortium of
addiction treatment, health, and human service providers.

This array is not specific to any particular philosophy of clinical
treatment and recovery, modality, or setting. It is a generic framework
within which potential applicants can conceptualize service arrays,
service capabilities, and appropriate managerial and administrative
processes, including evaluation.

Methods of implementing the components of this array, the staff who
deliver each service, the manner and setting in which different services
are delivered, etc., should be based on individual assessment and level
of care determination that considers 1) the needs of the individual; 2)
the extent to which there are clinical treatment services, recovery
support services, health, human services, housing, criminal justice
supervision, and labor training alternatives in the jurisdiction of
authority; and 3) the extent of available resources and agencies linked
through coordinated case management.

In many cases, it will be desirable to provide various components of the
array simultaneously, with the emphasis changing throughout the clinical
treatment and recovery process. For example, in the earlier, acute phase
of clinical treatment, heavier emphasis may be placed on clinical
treatment services; the emphasis may switch toward recovery support as
individuals move through rehabilitation and enter a maintenance phase of
clinical treatment and recovery. In some cases, recovery support
services alone will suffice.

###### **Examples of Number range CHAPTERClinical Treatment and Recovery Support Services** {#examples-of-number-range-chapterclinical-treatment-and-recovery-support-services .unnumbered}

Clinical treatment services are provided by individuals who are
licensed, certified, or otherwise credentialed to provide clinical
treatment services in the State, often in settings that address specific
treatment needs. Examples of clinical treatment services include the
following:

-   Screening/assessment

-   Brief intervention

-   Treatment planning

-   Detoxification

-   Medical care

-   Substance abuse education

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-   Individual counseling

-   Group counseling

-   Residential treatment

-   Pharmacological interventions

-   Co-occurring treatment services

    -   Family/marital counseling

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-   Case management

-   Relapse prevention

-   Continuing care (including face-to-face and telephone-based
    continuing care counseling)

-   Alcohol/drug testing

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-   Family services, including family/marriage counseling and parenting
    and child development services

-   Employment services and job training

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-   Outreach

    Recovery support services are typically provided by paid staff or
    volunteers familiar with how their communities can support people
    seeking to live free of alcohol and drugs, and are often peers of
    those seeking recovery. Some of these services may require
    reimbursement while others may be available in the community free of
    charge. Examples of recovery support services include the following:

-   Transportation to and from treatment, recovery support activities,
    employment, etc.

-   Employment services and job training

-   Case management/individual services coordination, providing linkages
    with other services (legal services, TANF, social services, food
    stamps, etc.)

-   Outreach

-   Relapse prevention

-   Housing assistance and services

-   Child care

-   Family/marriage education

-   Peer-to-peer services, mentoring, coaching

-   Self-help and support groups, such as 12-step groups, SMART
    Recovery, Women for Sobriety, etc.

-   Life skills

-   Spiritual and faith-based support

-   Education

-   Parent education and child development

-   Substance abuse education

###### **Definitions for Recovery Support Services**  {#definitions-for-recovery-support-services .unnumbered}

Transportation

Commuting services are provided to clients who are engaged in treatment-
and/or recovery support-related appointments and activities and who have
no other means of obtaining transportation. Forms of transportation
services may include public transportation or a licensed and insured
driver who is affiliated with an eligible program provider.

Employment Services and Job Training

These activities are directed toward improving and maintaining
employment. Services include skills assessment and development, job
coaching, career exploration or placement, job shadowing or internships,
résumé writing, interviewing skills, and tips for retaining a job. Other
services include training in a specific skill or trade to assist
individuals to prepare for, find, and obtain competitive employment such
as skills training, technical skills, vocational assessment, and job
referral.

Case Management

Comprehensive medical and social care coordination is provided to
clients to identify their needs, plan services, link the services system
with the client, monitor service delivery, and evaluate the effort.

Relapse Prevention

These services include identifying a client's current stage of recovery
and establishing a recovery plan to identify and manage the relapse
warning signs.

Housing Assistance and Services

These services include transitional housing, recovery living centers or
homes, supported independent living, sober housing, short-term and
emergency or temporary housing, and housing assistance or management.
These services provide a safe, clean, and sober environment for adults
with substance use disorders. Lengths of stay may vary depending on the
form of housing. This assistance also includes helping families in
locating and securing affordable and safe housing, as needed. Assistance
may include accessing a housing referral service, relocation,
tenant/landlord counseling, repair mediation, and other identified
housing needs.

Child Care

These services include care and supervision provided to a client's
child(ren), less than 14 years of age and for less than 24 hours per
day, while the client is participating in treatment and/or recovery
support activities. These services must be provided in a manner that
complies with State law regarding child care facilities.

Family/Marriage Counseling and Education

Services provided to engage the whole family system to address
interpersonal communication, codependency, conflict, marital issues and
concerns, parenting issues, family reunification, and strategies to
reduce or minimize the negative effects of substance abuse use on the
relationship.

Peer-to-Peer Services, Mentoring, Coaching

Mutual assistance in promoting recovery may be offered by other persons
who have experienced similar substance abuse challenges. These services
focus more on wellness than illness. Mentoring and coaching may include
assistance from a professional who provides the client counsel and/or
spiritual support, friendship, reinforcement, and constructive example.
Mentoring also includes peer mentoring which refers to services that
support recovery and are designed and delivered by peers---people who
have shared the experiences of addiction recovery. *Recovery support* is
included here as an array of activities, resources, relationships, and
services designed to assist an individual's integration into the
community, participation in treatment, improved functioning or recovery.

Life Skills

Life skills services address activities of daily living, such as
budgeting, time management, interpersonal relations, household
management, anger management, and other issues.

Spiritual and Faith-based Support

These services assist an individual or group to develop spiritually.
Activities might include, but are not limited to, establishing or
reestablishing a relationship with a higher power, acquiring skills
needed to cope with life-changing incidents, adopting positive values or
principles, identifying a sense of purpose and mission for one's life,
and achieving serenity and peace of mind. Faith-based services include
those provided to clients and using spiritual resources designed to help
persons in recovery to integrate better their faith and recovery. Such
services are usually provided in a religious or spiritual setting by
spiritual leaders or other staff who are knowledgeable about the
spiritual values of the community and are equipped to assist individuals
in finding spirituality. Services include, but are not limited to,
social support and community-engagement services, faith, or spirituality
to assist clients with drawing on the resources of their faith tradition
and community to support their recovery; mentoring and role modeling;
and pastoral or spiritual counseling and guidance.

Education

Supported education services are defined as educational counseling and
may include academic counseling, assistance with academic and financial
applications, and aptitude and achievement testing to assist in planning
services and support. Vocational training and education also provide
support for clients pursuing adult basic education, i.e., general
education development (GED) and college education.

Parent Education and Child Development

An intervention or treatment provided in a psycho-educational group
setting that involves clients and/or their families and facilitates the
instruction of evidence-based parenting or child development knowledge
skills. Parenting assistance is a service to assist with parenting
skills; teach, monitor, and model appropriate discipline strategies and
techniques; and provide information and advocacy on child development,
age appropriate needs and expectations, parent groups, and other related
issues.

###### **Examples of Recovery Support Service Rate Ranges**  {#examples-of-recovery-support-service-rate-ranges .unnumbered}

Table 1. Rate ranges for selected recovery support service types

+---------------------------------+-----------------+-----------------+
| Recovery support service type   | Unit of service | Range           |
+=================================+=================+=================+
| Most common types               |                 |                 |
+---------------------------------+-----------------+-----------------+
| Transportation                  | Round trip      | \$10--\$14 bus  |
|                                 |                 | pass            |
+---------------------------------+-----------------+-----------------+
| Employment  services or job     | Hour            | \$10--\$46.79   |
| training                        |                 |                 |
+---------------------------------+-----------------+-----------------+
| Case management                 | Hour            | \$10--\$56.89   |
+---------------------------------+-----------------+-----------------+
| Housing assistance or services  | Daily           | \$25--\$33      |
|                                 | transitional    |                 |
|                                 |                 | \               |
|                                 | Recovery House  | $1,359--\$2,000 |
|                                 | (monthly)       |                 |
+---------------------------------+-----------------+-----------------+
| Child care                      | Hour            | \$3.85--\$12    |
+---------------------------------+-----------------+-----------------+
| Family, marriage counseling,    | Hour            | \$5--\$81.98    |
| and education                   | (individual)    |                 |
+---------------------------------+-----------------+-----------------+
| Peer-to-peer services,          | Hour            | \$10--\$56.89   |
| mentoring, coaching             | (individual)    |                 |
|                                 |                 | \$15--\$20.50   |
|                                 | Hour (group)    |                 |
+---------------------------------+-----------------+-----------------+
| Other                           |                 |                 |
+---------------------------------+-----------------+-----------------+
| Life skills                     | Hour            | \$25--\$30      |
+---------------------------------+-----------------+-----------------+
| Spiritual and faith-based       | Hour            | \$5--\$10       |
| support                         |                 |                 |
+---------------------------------+-----------------+-----------------+
| Education                       | Hour            | \$20--\$25      |
|                                 | (individual)    |                 |
+---------------------------------+-----------------+-----------------+

### Appendix B: Services Included as Administrative Expenses

-   Eligibility determinations for clinical treatment and recovery
    services providers and for which services in the comprehensive array
    of clinical treatment and recovery support services will be included
    in the voucher reimbursement system

-   Management of a system for client eligibility determination and
    assessment for appropriate level of care

-   Fiscal/cost accounting mechanisms that can track voucher
    implementation

-   Management of information systems for tracking outcomes and costs,
    including the costs of data collection and reporting

-   Development of quality improvement activities, including technical
    assistance and training to attract, develop, and sustain new
    clinical treatment and recovery support providers

-   Marketing of vouchers to client and provider organizations

-   Oversight of standards and fraud and abuse issues

### Appendix CNumber range CHAPTER: Standards For The Access To Recovery (ATR) Program

Grantees will be expected to administer their ATR projects in a manner
consistent with good management practices. Grantees will have
flexibility in establishing standards appropriate and feasible for their
service delivery system and target population. However, once Grantees
have established standards for participating provider organizations,
they are expected to enforce such standards.

**Number range CHAPTERIn its application, the State should demonstrate
how it intends to:**

1.  **Ensure that clients receive a genuine, free, and independent
    choice among assessment, placement, clinical treatment, and recovery
    support services.**

> a\. For purposes of this program, choice is defined as a client being
> able to select among at least two providers which are qualified to
> provide the services needed by the client, among them at least one
> provider to which the client has no religious objection.

**2. Ensure that clients receive a clinical assessment and a level of
care determination from a qualified person and/or provider
organization.**

a.  States should describe the qualifications they require of
    individuals and/or providers that perform assessments and level of
    care determinations.

b.  States should describe steps they will take to prevent potential
    conflicts of interest among practitioners and/or provider
    organizations conducting screening, assessment and referral to
    clinical treatment and/or recovery support services.

**3. Ensure that clients receive appropriate services from clinical
treatment and recovery support programs.**

a.  To be eligible for voucher reimbursement, clinical treatment and
    recovery support programs should meet standards that are required by
    the State for other providers that provide the same type of services
    (e.g. residential, outpatient, family support services, etc.).

b.  Each State should document the eligibility requirements and program
    standards the State intends to use for each of the services proposed
    to be reimbursed under the voucher program. Eligibility requirements
    and standards should be documented for services across the entire
    array of recovery, as described in Appendix A, including eligibility
    requirements and standards for clinical treatment services and
    recovery support services. (For example, the State should document
    its eligibility requirements and standards for specific types of
    providers such as residential, outpatient, methadone, recovery
    support services, etc.) In the case of services for which no
    standards currently exist, the State must describe the process to be
    used to ensure that individuals receive appropriate services in safe
    settings from appropriate individuals. States must also describe how
    they intend to monitor compliance with these standards and/or
    processes.

    **4. Expand the range of clinical treatment and recovery support
    services providers that meet appropriate standards.**

> a\. States should describe how they intend to provide technical
> assistance and training to providers of clinical treatment and
> recovery services as described in Appendix A in order for them to meet
> State standards.

5\. Ensure that outcome and financial data is reported in a timely
manner.

a.  States should describe how they intend to ensure that outcome data
    are reported, as required in Section I-2.1 of the funding
    announcement.

### Appendix D: Screening, Assessment, and Level of Care Determination

###### **Screening** {#screening .unnumbered}

The purpose of screening is to quickly and cost-effectively rule out
people without substance abuse problems and to identify the need for
specialized substance abuse treatment.

The basic questions asked in the screening process are: 1) is a
substance abuse problem present; and 2) does it require specialized
care. Although we often think individuals seeking clinical treatment
have been previously screened, some individuals seek specialized
treatment directly.

If screening suggests an individual probably has a problem likely to
require specialized treatment, the next step in the sequence may be
thought of as the problem assessment.

###### **Assessment** {#assessment .unnumbered}

Assessment is the systematic process of interaction with an individual
to observe, elicit, and subsequently assemble the relevant information
required to manage his or her problems, both immediately and for the
foreseeable future. An assessment gauges which of the available clinical
treatment and recovery services options are likely to be most
appropriate for the individual being assessed. Hence, assessment must
occur prior to any referral of the individual to a particular kind of
clinical treatment and/or recovery support service. When the same
general approach is applied to all or most clients, assessment may have
little impact.

*Purpose of Assessment*

-   To characterize a problem --

> Substance abuse problems differ from person to person, often both in
> degree and in kind. What should emerge from an assessment is a
> detailed picture of the particular kind of substance abuse problem
> manifested by a particular individual at a particular point in time.
>
> In the absence of a clear, unambiguous picture at initial contact,
> appropriate decisions regarding care for the present and future may be
> difficult.

-   To characterize an individual --

> Substance abuse problems do not occur in a vacuum. Individuals who
> manifest them are at least as different from one another as they are
> from people without substance use disorders.
>
> Some of these problems may be the result of abuse of drugs or alcohol;
> some may result in using drugs or alcohol; others may be independent
> problems. All are important in themselves, requiring assessment, (and
> often attention), in clinical treatment and/or recovery support
> programs. Individual characteristics may affect a person's acceptance
> (and, in consequence, the eventual outcome) of various forms of
> clinical treatment and/or recovery support services. Thus, detailed
> knowledge of individual characteristics can help provide the client
> with a list of appropriate clinical treatment and/or recovery support
> service options.

-   To identify appropriate clinical treatment and/or recovery support
    service options--

> Assessment prior to clinical treatment and/or recovery support forms
> the basis on which individuals are provided a list of clinical
> treatment and/or recovery support options appropriate to their needs.
>
> Additional information on the individual will need to be gathered by
> program staff following the selection of a clinical treatment and/or
> recovery support program to plan the individual's ongoing course of
> care.

###### **Level of Care Determination** {#level-of-care-determination .unnumbered}

Level of care determination is achieved through the client's selection
of clinical treatment and recovery support alternatives that are both
available and most likely to facilitate a positive outcome in a
particular individual. Level of Care Determination:

-   Focuses on matching clinical treatment and/or recovery support
    services to individual needs within the framework of client choice

-   Defines expectations for each stage of care:

    -   Acute intervention, including detoxification

    -   Rehabilitation

    -   Maintenance and relapse prevention

While choice among the various clinical treatment and/or recovery
support services options resides with the individual, the assessor is
responsible to ensure that the individual is fully conversant with all
of the therapeutic alternatives available from eligible providers.

*The Level of Care Determination Process*

Level of Care determination is a complex matter, requiring consideration
of individuals and their substance abuse problems, and knowledge of
available clinical treatment and recovery support services by both the
assessor and the client.

The following general descriptors of clinical treatment and recovery
support services represent the kinds of information most useful to help
identify appropriate levels of care and clinical treatment and/or
recovery support service options for individuals with substance abuse
problems. When presented to clients in every-day language, the following
information can assist clients in making an informed choice of the
clinical treatment and/or recovery support service option(s) that may
meet their needs:

-   Philosophy and orientation of the program (e.g., medical model,
    social model, spiritual model, etc.);

-   Stage of substance abuse problem or recovery at which the clinical
    treatment and/or recovery support service is directed (e.g.,
    detoxification, rehabilitation, maintenance);

-   Setting of the program (e.g., inpatient, outpatient, residential)
    and staffing; and

-   Therapeutic approach/type of intervention

###### **Additional Resources for Screening, Assessment, and Level of Care Determination** {#additional-resources-for-screening-assessment-and-level-of-care-determination .unnumbered}

**I. Resources to Implement Screening**

In health care, screening is a process to identify people who have, or
are at risk for, an illness or disorder. The purpose of screening is to
target persons for clinical treatment and/or recovery support services,
thus reducing the long-term morbidity and mortality related to the
condition. In addition, by intervening early and raising the
individual's level of concern about risk factors and substance-related
problems, screening for drug and alcohol problems in community settings
can reduce subsequent use.

Two types of screening procedures are typically used. The first includes
self-report questionnaires and structured interviews; the second,
clinical laboratory tests that can detect biochemical changes associated
with excessive alcohol consumption or illicit drug use.

A variety of screening instruments are available. The majority of
studies and implementation efforts have focused on screening for alcohol
problems. The CAGE and AUDIT are the most commonly used screening tools.
The DAST has also been used in conjunction with the AUDIT in several
projects, where there has been an effort to implement this approach for
persons with or at risk for a substance use disorder. Several new
instruments have been developed, but not yet rigorously tested, to
assess harmful use of either alcohol or drugs (e.g., the CAGE-D, the
ASSIST, the TCUDS, the GAIN-QS, the PDES).

> Brown, RL and Rounds LA. 1995. Conjoint screening questionnaires for
> alcohol and other drug abuse: criterion validity in a primary care
> practice. *Wisconsin Medical Journal*, 94, 135-140.
>
> Brown R, Leonard T, Saunders LA, et al. (1997). A two-item screening
> test for alcohol and other drug problems. *Journal of Family
> Practice*, 44, 151-160.

A bibliography with descriptions and evaluations of various interview,
questionnaire, and laboratory test screening approaches is available
from Project Cork.

> Project Cork. 2002. *CORK Bibliography: Screening Tests.* 2001-2002,
> 58 Citations.
> <http://www.projectcork.org/bibliographies/data/Bibliography_Screening_Tests.html>

Screening instruments have been developed or modified for use with
different target populations, notably adolescents, offenders within the
criminal justice system, welfare recipients, women, and the elderly.
Several have been translated into other languages and have been
evaluated for cultural sensitivity. Again, SAMHSA is not requiring a
specific instrument or protocol, but choice of instruments or laboratory
tests must be justified.

It is well recognized that screening instruments used with adolescents
must be developmentally appropriate, valid and reliable, and practical
for use in busy medical settings.  One example of a brief substance
abuse screening instrument recently developed specifically for use with
adolescents is the CRAFFT test.

> Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. 2002. Validity
> of the CRAFFT substance abuse screening test among adolescent clinic
> patients. *Arch Pediatr Adolesc Med*. 156(6): 607-14.

Additional screening tests and procedures targeted at
[adolescents]{.underline}, including the PDES and the GAIN-QS, are
described in these publications:

> Winters KC. 1992. Development of an adolescent alcohol and other drug
> abuse screening scale: Personal Experience Screening Questionnaire.
> *Addict Behav*. 17(5): 479-90.
>
> Winters KC. 1999. *Screening and Assessing Adolescents For Substance
> Use Disorders.* Treatment Improvement Protocol (TIP) Series 31 DHHS
> Publication No. (SMA*)* 99-3282.
>
> Winters KC. 1999. *Treatment of Adolescents With Substance Use
> Disorders.\
> *Treatment Improvement Protocol (TIP) Series 32*.* DHHS Publication
> No. (SMA*)* 99-3283.
>
> Winters KC. 2001. Assessing adolescent substance use problems and
> other areas of functioning: State of the art. In: PM Monti, SM. Colby,
> and TA. O\'Leary (eds). *Adolescents, Alcohol, and Substance Abuse:
> Reaching Teens Through Brief Interventions.* New York, Guilford
> Publications, Inc., pp. 80-108.
>
> Dennis ML 1998. *Global Appraisal of Individual Needs (GAIN) manual:
> Administration, Scoring and Interpretation,* (Prepared with funds from
> CSAT TI 11320). Bloomington IL: Lighthouse Publications.
> <http://www.chestnut.org/LI/GAIN/GAIN_QS/index.html>
>
> Martino S, Grilo CM, and Fehon DC 2000. Development of the drug abuse
> screening test for adolescents (DAST-A). *Addictive Behaviors* 25(1):
> 57-70.

Screening tests and procedures targeted at the [elderly]{.underline} are
described in these publications:

> Blow, F.C. Consensus Panel Chair. 1998. *Substance Abuse Among Older
> Adults.* Treatment Improvement Protocol (TIP) Series 26. DHHS
> Publication No. (SMA) 98-3179.
>
> Blow FC and Barry KL. 1999-2000. Advances in alcohol screening and
> brief intervention with older adults. *Advances in Medical
> Psychotherapy*. 10:107-124

Screening tests and procedures targeted at persons in the [criminal
justice]{.underline} system are described in these publications:

> Inciardi JA Consensus Panel Chair 1994. *Screening and Assessment for
> Alcohol and Other Drug Abuse Among Adults in the Criminal Justice
> System.* Treatment Improvement Protocol (TIP) Series 7. DHHS
> Publication No. (SMA) 94B2076
>
> Peters, RH, Greenbaum, PE, Steinberg, ML, Carter, CR, Ortiz, MM, Fry,
> BC, Valle, SK. 2000. Effectiveness of screening instruments in
> detecting substance use disorders among prisoners. *Journal Substance
> Abuse Treatment*: 18(4): 349-58.
>
> Simpson DD. 2001. Core set of TCU forms. Fort Worth: Texas Christian
> University, Institute of Behavioral Research.
> [www.ibr.tcu.edu](http://www.ibr.tcu.edu/).

Efforts are ongoing to develop methods to better screen people with
co-occurring substance use and mental disorders.

####### II. Assessment Instruments {#ii.-assessment-instruments .unnumbered}

Substance abuse assessment instruments are designed to determine the
precise nature and severity of an individual's problems. Some
instruments are also designed to help pinpoint specific diagnoses. While
the results of assessment instruments do not necessarily specify the
service needs of clients, the data collected from these instruments can
help determine a client's level of care need and, thus, the options of
eligible service providers.

-   **Adult Assessment Instruments**

***Addiction Severity Index (ASI)***

ASI is a 30 to 40-minute, interviewer-administered instrument that
assesses severity of alcohol and drug problems across several domains.
The ASI has been tested extensively and used widely for initial client
assessments and to measure client progress and outcomes. The ASI should
be administered by trained clinicians.

McLellan, A.T.; Luborsky, L.; O\'Brien, C.P.; Woody, G.E. An improved
diagnostic instrument for substance abuse patients: The Addiction
Severity Index. *J Nerv Ment Dis* 168:26-33, 1980.\
\--and/or\--\
McLellan, A.T.; Kushner, H.; Metzger, D.; Peters F.; et al. The fifth
edition of the Addiction Severity Index. *J Subst Abuse Treat*
9:199-213, 1992.

***Substance Use Disorders Diagnostic Schedule (SUDDS-IV)***

"The SUDDS-IV is a comprehensive diagnostic assessment interview
providing definitive documentation for substance-specific abuse or
dependence diagnoses based on DSM-IV-TR criteria. It also screens for
depression and anxiety disorders. In addition to diagnostic
documentation, the SUDDS-IV provides valuable information for treatment
planning and patient placement." (Source:
[www.evinceassessment.com](http://www.evinceassessment.com/))

Harrison, P. & Hoffman, N. (1987). Substance Use Disorders Diagnostic
Schedule (SUDDS). St. Paul, MN: Norman G. Hoffman.

***Minnesota Multiphasic Personality Inventory (MMPI)***

"The Minnesota Multiphasic Personality Inventory (MMPI) is an objective
verbal inventory designed as a personality test for the assessment of
psychopathology consisting of 550 statements, 16 of which are repeated.
The replicated statements were originally included to facilitate the
first attempt at scanner scoring. Though they are no longer needed for
this purpose, they persist in the inventory." (Source:
http://www.cps.nova.edu/\~cpphelp/MMPI-2.html)

Hathaway, S. & McKinley, J. Manual for the Minnesota Multiphasic
Personality Inventory. New York: Psychological Corporation; 1951, 1967,
1983.\
\--and/or\--\
Hathaway, S.; McKinley, J.; Butcher, J.; Dahlstrom, W.; Graham, J.;
Tellegen, A.; et al. Minnesota Multiphasic Personality Inventory-2:
manual for administration. Minneapolis: University of Minnesota Press;
1989.

***The Recovery Attitude and Treatment Evaluator (RAATE)***

"The RAATE-CE and QI instruments were designed to assist in placing
patients into the appropriate level of care at admission, in making
continued stay or transfer decisions during treatment (utilization
review), and documenting appropriateness of discharge. Both instruments
demonstrate good face and rational-expert content validity." (Source:
NIAAA)

Mee-Lee, D. An instrument for treatment progress and matching: The
Recovery Attitude and Treatment Evaluator (RAATE). *J Subst Abuse Treat*
5:183-186, 1988.\
\--and/or\--\
Mee-Lee, D.; Hoffmann, N.G.; and Smith, M.B. *The Recovery Attitude And
Treatment Evaluator Manual.* St. Paul, Minnesota: New Standards, Inc.,
1992.

-   **Adolescent Assessment Instruments**

***Comprehensive Adolescent Severity Inventory (CASI)***

CASI measures education, substance use, use of free time, leisure
activities, peer relationships, family history and intrafamilial
substance use, psychiatric status, and legal history. The CASI also
incorporates results from urine drug screens and observations from the
assessor. Psychometric studies on the CASI support the instrument's
reliability and validity.

Meyers, Kathleen. *Comprehensive Adolescent Severity Inventory (CASI).*
Philadelphia, PA: Penn/VA Center for Studies of Addiction, 1996. c. 176
p. \[RJ 503.7 M4 1996\]

***Global Assessment of Individual Needs (GAIN)***

> Dennis, ML 1998. *Global Appraisal of Individual Needs (GAIN) manual:
> Administration, Scoring and Interpretation,* (Prepared with funds from
> CSAT TI 11320). Bloomington IL: Lighthouse Publications.
> <http://www.chestnut.org/LI/GAIN/GAIN_QS/index.html>
>
> Winters, KC. 1999. *Screening and Assessing Adolescents For Substance
> Use Disorders.* Treatment Improvement Protocol (TIP) Series 31 DHHS
> Publication No. (SMA*)* 99-3282.

####### III. Diagnostic Criteria {#iii.-diagnostic-criteria .unnumbered}

***Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition*
(DSM-IV)**

DSM-IV includes the most widely accepted criteria for diagnosing
substance abuse and mental disorders. Based on data collected during an
assessment, the DSM criteria for substance use disorders can be used to
determine if someone has a "substance abuse" or "substance dependence"
diagnosis. DSM-IV was first published in 1994 by the American
Psychiatric Association, Washington D.C.

**IV. Level of Care Determination, Continued Stay, and Discharge
Criteria**

***Patient Placement Criteria for the Treatment of Substance-Related
Disorders***

The American Society of Addiction Medicine (ASAM) published the second
edition of its *Patient Placement Criteria for the Treatment of
Substance-Related Disorders* (ASAM PPC-2) in 1996. ASAM's PPC-2R
presents the criteria for determining which level of services best fits
a client's needs. The PPC-2R now has both adult and adolescent criteria
and the appropriate criteria should be used for each of these groups.

######## **RAATE**  {#raate .unnumbered}

######## "The RAATE-CE and QI instruments were designed to assist in placing patients into the appropriate level of care at admission, in making continued stay or transfer decisions during treatment (utilization review), and documenting appropriateness of discharge. Both instruments demonstrate good face and rational-expert content validity." (Source: NIAAA) {#the-raate-ce-and-qi-instruments-were-designed-to-assist-in-placing-patients-into-the-appropriate-level-of-care-at-admission-in-making-continued-stay-or-transfer-decisions-during-treatment-utilization-review-and-documenting-appropriateness-of-discharge.-both-instruments-demonstrate-good-face-and-rational-expert-content-validity.-source-niaaa .unnumbered}

Mee-Lee, D. An instrument for treatment progress and matching: The
Recovery Attitude and Treatment Evaluator (RAATE). *J Subst Abuse Treat*
5:183-186, 1988.\
\--and/or\--\
Mee-Lee, D.; Hoffmann, N.G.; and Smith, M.B. *The Recovery Attitude And
Treatment Evaluator Manual.* St. Paul, Minnesota: New Standards, Inc.,
1992.

### Appendix E: Examples of How a State Could Implement a Voucher Program

Following are two examples of how an ATR grantee could use vouchers for
assessment and level of care determination, as well as for substance use
clinical treatment and/or recovery support services. Applicants should
be innovative in their approaches.

***Please note that technical assistance is available to all applicants
to assist them in the development and implementation processes. We
encourage all applicants to seek such assistance.***

**Example 1: State of New Chester**

Grant Award Date: August, 2005

[Implementation Date]{.underline}: December 2005

[Client Target for Year 1]{.underline}: 2,333

[Client Target for Year 2]{.underline}: 3,696

[Client Target for Year 3]{.underline}: 3,696

**[Target Area]{.underline}**: Statewide (35 counties)

**[Target Populations]{.underline}:** The State of New Chester Access to
Recovery (ATR) initiative will focus on delivering services geared
toward the following high-risk, underserved populations:

1.  Substance abusing adolescents and young adults.

2.  Low income individuals in crisis who are involved with child
    protective services, shelters and medical clinics as a result of
    drug dependence and abuse.

> Special emphasis and outreach is being placed on adult women.

3.  Adults 18 and over who are involved with the criminal justice
    system/drug courts

> or those who are exiting the correctional system.

**[Outreach to Providers]{.underline}**: New Chester recognized it had
to set a minimum level of eligibility criteria and standards for each
provider within the clinical treatment and recovery support services
network to provide quality treatment services to its citizens. All
clinical treatment organizations must meet existing State licensing and
certification standards for clinical treatment and assessment. For
recovery support services not currently offered through New Chester's
State Department of Drug and Alcohol Substance Abuse Services (SDDASAS),
ATR recovery specialists refer clients to recovery support service
providers who meet grantee-established eligibility standards. Therefore,
in accordance with State administrative procedures, New Chester
published eligibility criteria and standards and created a list of
eligible entities to provide assessment and level of care determination,
as well as clinical treatment and recovery support services. New Chester
makes diligent efforts to conduct outreach and marketing to providers
previously unable to compete for Federal funds, including faith-based
and community organizations. New Chester uses educational meetings to
introduce the concept of ATR, provide enrollment information, and to
give information about the recovery support services ATR vouchers will
support. Enrollment meetings are utilized to enroll recovery support
providers, to distribute the eligibility requirements for participation,
and to offer help to providers for attaining the eligibility standards
required for ATR participation.

Any provider interested in being part of the voucher program will be
required to participate in a training program. Once a provider has
completed the training, it will be enrolled officially in the ATR
voucher program and the provider name and faith-based affiliation, if
any, are added to the resource listing through the Helpline. The list of
new providers is shared with county coordinators. At the outset of their
voucher initiative, New Chester developed an eligibility application
process and incentives to improve outcomes. As part of the application
process, providers agreed to receive 90% of the reimbursement rate for
their services; 10% was withheld and set aside to be used to reimburse
and encourage positive client outcomes.

Fifty (50) new clinical treatment providers (Statewide) met the
licensing and certification criteria already established by the State.
When New Chester implemented, 28 recovery support providers, including
13 faith-based organizations, had been identified, met the eligibility
criteria, and agreed to the reimbursement rates established by New
Chester. The recovery support service providers agreed to the grantee
established definitions of recovery support services and the
reimbursement rates for these services (developed by the State). All of
the aforementioned providers signed Memoranda of Understanding to
provide ATR services should they be selected by a client. All received
at least one GPRA training session. Outreach/recruitment activities and
training is ongoing. Non-traditional providers unable to meet standards
will receive technical assistance and training to help them meet the
requirements. Faith-based programs who have the ability to provide
clinical treatment services will receive assistance for achieving
licensure. The New Chester Faith-Based Association (FBA) will have
responsibility for certifying unlicensed faith-based organizations that
wish to provide recovery support services

**[Outreach to Clients:]{.underline}** New Chester proposed to expand
its current addiction programs by offering voucher driven alcohol and
drug treatment/recovery support services Statewide. The scheduled
implementation date was November 1, 2004.

New Chester established a 24-hour, 7-day-a-week telephone line for their
ATR project (800-FOR-HELP). This number made available a list of
eligible assessment, treatment, and recovery support service providers
(throughout the State) for the voucher treatment system. New Chester is
committed to providing an administrative process which ensures
individuals receive appropriate services in safe settings and services
delivered by appropriate individuals. When the program opened it doors
as scheduled, the 800 telephone number had been activated. This number,
the New Chester ATR website, and a major media kick-off blitz, gave the
public direct and ready access to the multiple portals of entry for both
potential clients and ongoing recruitment of potential caregivers.
Potential clients are also able to do a brief screening and self
assessment via the telephone or online. Initial appointments can be made
by telephone or sent electronically. Referrals to the ATR are provided
by partners at various sites, such as the public assistance/ child
welfare offices, the juvenile and adult courts, the prison and jail
sites and medical hospitals and clinics.

Additionally, all key staff were in place and all Helpline call center
employees had attended thorough ATR customer service orientation and
training on dealing with difficult/suicidal clients.

**[How vouchers are issued]{.underline}**: A critical component of New
Chester's voucher program is its Electronic Information System (EIS). As
clients submit a *request for services* from New Chester, they enter an
electronic voucher system. A first task is to establish a client's
identity and ascertain whether she or he had previously participated in
the voucher program. If a client is new to the voucher system, they
receive a *unique client number* and an initial client record is
created. Initial contact information includes, at a minimum, name,
social security number, birth date, and -- where possible- substance use
problem information. When the vouchers are issued (electronically) the
client acknowledges by signature that he/she invoked their right to
select from a list of providers appropriate to meet their assessed
treatment/recovery support needs. The intake/assessment staff does a
telephone follow up after 72 hours to ascertain whether or not the
client kept the appointment. A bi-monthly call is made to the
facility/organization to confirm the client is still in attendance. Any
client who does not present for services is terminated from the ATR
rolls after 60 days of non-activity. To re-enroll, a client must repeat
the intake and assessment process. Separate vouchers are issued for each
type of service. Vouchers have no cash value.

New Chester specifies that payments to providers be calculated on a
service-by-service basis (unbundled), using a standardized rate
schedule. New Chester specified that 90% of the rate be invoiced when
services were delivered, and that the additional 10% be generated
following outcomes reporting. In New Chester, services allowable are
determined by the particular type of voucher issued for the client and
by the services offered by the submitting provider. Individual services
are restricted to clearly defined minimum and maximum time limits and
established reimbursement rates. New Chester provides a detailed account
of the voucher and service types, rate schedule, incentive payment
conditions, and restrictions in effect for their voucher program

**[Accountability]{.underline}**: New Chester is managing performance of
ATR providers through outcomes monitoring, including tracking outcomes
in SAMHSA's seven identified domains. New Chester monitors provider
reporting of outcomes information on a monthly basis. At the end of the
first 6 months of the first year, New Chester recognized six providers
needed technical assistance to accurately report outcomes information.
New Chester provided such technical assistance in a timely manner. At
the end of the first year, however, four of the six providers were still
unable to provide the outcomes information in each of the seven domains.
As a result, New Chester declared these four providers ineligible for
the voucher program for the next year.

New Chester is utilizing a variety of administrative controls to
safeguard potential fraud and abuse. An independent auditor will conduct
a yearly audit pursuant to OMB Circular No. A-133. Unique client
identification numbers will assure there is no duplication of services
and payments. On-site audits will be done to assess the need for
culturally competent services. Satisfaction surveys will be given to
clients. All certified care providers will have to be recertified on a
yearly basis. Program monitors will conduct random site visits twice a
year to review client files and provider documentation. All patient data
will be tracked electronically.

**Example 2: Blue Mountain Tribal Coalition**

Grant Award Date: August, 2005

[Implementation Date]{.underline}: December 2005

[Client Target for Year 1]{.underline}: 2,476

[Client Target for Year 2]{.underline}: 3,596

[Client Target for Year 3]{.underline}: 3,596

> .

**[Target Area]{.underline}**: The Blue Mountain Tribal Coalition is
implementing its ATR project in five designated counties between North
and South Dakota.

**[Target Populations]{.underline}**: The Blue Mountain Tribal Coalition
is using Access to Recovery (ATR) to expand services to rural- and
urban-dwelling American Indian/Alaska Natives (AI/AN) residing in North
and South Dakota.

**[Outreach to Providers]{.underline}**: Prior to launching its voucher
program, Blue Mountain conducted outreach to a wide range of substance
abuse service providers---both those involved in clinical treatment and
those involved in recovery support services. Outreach to enroll new
clinical treatment and recovery support service providers included
recruitment meetings, mass mailings, in-service trainings, public
service announcements, and displays at conferences. Blue Mountain
recognized it had to set a minimum level of eligibility criteria and
standards for each provider within the clinical treatment and recovery
support services network to provide quality treatment services to its
citizens. Blue Mountain encouraged providers to become eligible
organizations, explaining that the program would be most successful if
clients have access to a variety of treatment and recovery service
choices. Prior to implementation, Blue Mountain recruited 48 Tribal
Councils and Indian Health provider organizations that provided
resolutions demonstrating an interest in joining the ATR provider
referral list.  Clinical treatment providers must be licensed and/or
certified.  Recovery support service providers (such as healers or
elders) must be in good standing with their respective tribal
organization.  Two major eligibility conditions were required of
providers: 1) all providers must comply with Blue Mountain established
ATR eligibility standards and 2) agreeing to provide the required
outcomes (the SAMHSA required seven domains) and financial data.
Nontraditional providers unable to meet eligibility standards receive
technical assistance and training to help them meet the requirements.
Faith-based and Native Healing programs who have the ability to provide
clinical treatment services will receive assistance for achieving
licensure. The Blue Mountain Spiritual Healing Association (BMSHA) will
have responsibility for certifying unlicensed faith-based organizations
wishing to provide recovery support services. An Outreach Coordinator
position has been created to conduct outreach and marketing to providers
previously unable to compete for Federal funds, including Healing and
other faith-based and community organizations. Blue Mountain uses
initial educational meetings to introduce the concept of ATR, provider
enrollment information, and information about the recovery support
services ATR vouchers will support. Enrollment meetings are utilized to
enroll recovery support providers, to distribute the eligibility
requirements for participation, and to offer help to providers for
attaining eligibility standards required for ATR participation.
Organizing these events has been an efficient way for Blue Mountain to
disseminate information and to answer questions and concerns posed by
recovery support service providers.

**[Outreach to Clients]{.underline}**:

With ATR, clients would receive vouchers to redeem at the providers of
their choice. To recruit clients, Blue Mountain is conducting
significant outreach in a number of ways. Blue Mountain is using a broad
range of professional and community sources including self referral,
family, friends, self-help organizations, Tribal organizations, Tribal
elders, Healers, faith-based organizations, human service organizations
and professionals, health care professionals and centers,
community-based organizations, employers, educational institutions,
substance abuse treatment facilities, and recovery management services.
The Blue Mountain Coalition established an 800 information number and a
24-hour access hotline through which certified addiction professionals
conduct screenings, thereby facilitating access to clinical treatment
and/or recovery support services.

**[How vouchers are issued]{.underline}**:

> [Assessment voucher]{.underline}: The screening yields the assessment
> voucher. At the scheduled time, the client is assessed by qualified
> and trained staff. The assessment includes the Addiction Severity
> Index (ASI).
>
> [Clinical treatment voucher]{.underline}**:** Based on the results of
> the comprehensive assessment, a clinical treatment voucher is
> generated which includes level of care recommendations and all
> providers that offer the type and level of care indicated by the
> assessment. The automated voucher system enables the assessor to help
> the client compare various clinical treatment providers\' services and
> capabilities so the client can make an informed choice. The clinical
> treatment voucher will contain the client's and assessor\'s signatures
> along with the client\'s choice of provider, clear instructions for
> the client\'s next steps -- admission date, transportation
> arrangements (if needed), pre-treatment supports, recovery supports,
> etc.
>
> [Recovery support service voucher]{.underline}: An assessment provider
> offers multiple choices to the client in terms of [recovery
> supports]{.underline} while awaiting clinical treatment, during
> clinical treatment, and during extended treatment along with clear
> instructions about next steps. The assessment produces a recovery
> supports voucher which includes services that might benefit the client
> based upon information gathered in the assessment. After the client
> chooses recovery supports, the client and assessor sign the voucher.
> The recovery supports voucher may be updated as the need for
> additional services arises during the course of the recovery process
> and in preparation for discharge.

**[Accountability]{.underline}**:

Blue Mountain put processes in place to prevent, detect, and investigate
incidents of fraud and/or potential abuse. Since Blue Mountain is using
electronic tracking systems, ATR clients will be cross-referenced
against other public data systems to identify the receipt of duplicative
services and potential payments for the same service by more than one
payer. Blue Mountain plans to conduct random audits of provider billings
and service data. Blue Mountain will also be conducting on-site audits
to assess the need for culturally competent services. Blue Mountain
required an initial review of provider service and billing practices
before a provider was eligible to participate in ATR. In addition, Blue
Mountain will be utilizing client satisfaction surveys and medical chart
and claims payment audits to reduce the likelihood of waste, fraud and
abuse.

Blue Mountain monitored provider reporting of outcomes information on a
monthly basis. At the end of the first 6 months of the first year, Blue
Mountain recognized ten providers needed technical assistance to
accurately report outcomes information. Blue Mountain provided such
technical assistance in a timely manner. At the end of the first year,
however, four of the ten providers were still unable to provide the
outcomes information in each of the seven domains. As a result, Blue
Mountain declared these four providers ineligible for the ATR voucher
program for the next year.

### Appendix F -- 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-3 of this announcement under "Guidance for Submission of
    Electronic 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-3 of this announcement under "Guidance
    for Submission of Electronic 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:

```{=html}
<!-- -->
```
-   Face Page (Standard Form 424 v2, 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

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

-   Checklist (a form in PHS 5161-1)

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

```{=html}
<!-- -->
```
-   Provisions relating to confidentiality and participant protection
    specified in Section V-1 of this announcement.

-   Budgetary limitations as specified in Sections 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 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 G: 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**

ILLUSTRATION 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**

ILLUSTRATION 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 \$186,600 is effective for all FY 2007 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 H: Managing On The Basis Of Reasonable Costs

States are encouraged to manage the program on the basis of reasonable
costs. Proposed per person costs for treatment and recovery support
services to be provided under this initiative should be included in the
application. In cases where it is not possible to include costs that are
based on prior experience, the application should include an estimate of
the cost of the service, as well as a plan and timeline for developing
cost data based on experience.

> The following are considered reasonable ranges by treatment or
> modality:

-   Screening/Brief Intervention/Brief Treatment/Outreach/Pretreatment
    Services - \$200 to \$1,200

-   Outpatient (Non-Methadone) - \$1,000 to \$5,000

-   Outpatient (Methadone) - \$1,500 to \$8,000

-   Residential - \$3,000 to \$10,000

    If the State deviates from these costs, it should provide a
    justification for doing so, in order for SAMHSA to determine
    reasonableness of costs. Reasonable cost is based on actual cost of
    providing such services, including direct and indirect cost of
    providers and excluding any costs that are unnecessary in the
    efficient delivery of services covered by the program (Center for
    Medicare and Medicaid Services, 2003). While cost ranges for
    recovery support services are not specified above, due to the great
    variations that exist, applicants are expected to provide costs for
    recovery support services that they intend to provide. Per person
    costs for each modality should be computed by dividing the number of
    persons served in each modality by the amount of the project budget
    used to fund that program component after subtracting out the costs
    of required data collection and submission.

### Appendix I

Number range CHAPTERForm Approved

OMB No. 0930-0208

Expiration Date 01/31/2007

**CSAT GPRA Client Outcome Measures**

**for Discretionary Programs**

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.*

B. DRUG AND ALCOHOL USE

+------------------------------------------+----------------+---------+
|                                          | **Number\      | **DON'T |
|                                          | of Days        | KNOW**  |
|                                          | REFUSED**      |         |
+------------------------------------------+----------------+---------+
| **1. During the past 30 days how many    |                | []      |
| days have you used the following:**      |                | {.mark} |
+------------------------------------------+----------------+---------+
| a\. Any alcohol ***\[IF ZERO, SKIP TO    | \|\_\_\_       |         |
| ITEM B1c.\]***                           | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| b1. Alcohol to intoxication (5+ drinks   | \|\_\_\_       |         |
| in one sitting)                          | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| b2. Alcohol to intoxication (4 or fewer  | \|\_\_\_       |         |
| drinks in one sitting and felt high)     | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| c\. Illegal drugs                        | \|\_\_\_       |         |
|                                          | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| d\. Both alcohol and drugs (on the same  | \|\_\_\_       |         |
| day)                                     | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| []{.mark}                                |                | []      |
|                                          |                | {.mark} |
+------------------------------------------+----------------+---------+
| **Route of Administration Types:**       | **Number\      | **      |
|                                          | of Days RF     | Route\* |
| 1\. Oral 2. Nasal 3. Smoking 4. Non-IV   | DK**           | RF DK** |
| injection 5. IV                          |                |         |
|                                          |                |         |
| \*Note the usual route. For more than    |                |         |
| one route, choose the most severe. The   |                |         |
| routes are listed from least severe (1)  |                |         |
| to most severe (5).                      |                |         |
+------------------------------------------+----------------+---------+
| **2. During the past 30 days, how many   |                |         |
| days have you used any of the            |                |         |
| following:**                             |                |         |
+------------------------------------------+----------------+---------+
| a\. Cocaine/Crack                        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| b\. Marijuana/Hashish (Pot, Joints,      | \|\_\_\_       | \|\_\   |
| Blunts, Chronic, Weed, Mary Jane)        | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| c\. Opiates:                             |                |         |
+------------------------------------------+----------------+---------+
| 1\. Heroin (Smack, H, Junk, Skag)        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 2\. Morphine                             | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 3\. Diluadid                             | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 4\. Demerol                              | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 5\. Percocet                             | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 6\. Darvon                               | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 7\. Codeine                              | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 8\. Tylenol 2,3,4                        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 9\. Oxycontin/Oxycodone                  | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| d\. Non-prescription methadone           | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| e\. Hallucinogens/psychedelics, PCP      | \|\_\_\_       | \|\_\   |
| (Angel Dust, Ozone, Wack, Rocket Fuel)   | \_\|\_\_\_\_\| | _\_\_\| |
| MDMA (Ecstasy, XTC, X, Adam), LSD (Acid, |                |         |
| Boomers, Yellow Sunshine), Mushrooms or  |                |         |
| Mescaline                                |                |         |
+------------------------------------------+----------------+---------+
| f\. Methamphetamine or other             | \|\_\_\_       | \|\_\   |
| amphetamines (Meth, Uppers, Speed, Ice,  | \_\|\_\_\_\_\| | _\_\_\| |
| Chalk, Crystal, Glass, Fire, Crank)      |                |         |
+------------------------------------------+----------------+---------+

B. DRUG AND ALCOHOL USE (Continued)

+------------------------------------------+----------------+---------+
| **Route of Administration Types:**       |                |         |
|                                          |                |         |
| 1\. Oral 2. Nasal 3. Smoking 4. Non-IV   |                |         |
| injection 5. IV                          |                |         |
|                                          |                |         |
| \*Note the usual route. For more than    |                |         |
| one route, choose the most severe. The   |                |         |
| routes are listed from least severe (1)  |                |         |
| to most severe (5).                      |                |         |
+------------------------------------------+----------------+---------+
| **2. During the past 30 days, how many   | **Number\      | **      |
| days have you used any of the            | of Days RF     | Route\* |
| following:**                             | DK**           | RF DK** |
+------------------------------------------+----------------+---------+
| g\. 1. Benzodiazepines: Diazepam         | \|\_\_\_       | \|\_\   |
| (Valium); Alprazolam (Xanax); Triazolam  | \_\|\_\_\_\_\| | _\_\_\| |
| (Halcion); and Estasolam (Prosom and\    |                |         |
| Rohypnol--also known as roofies, roche,  |                |         |
| and cope)Number range CHAPTER            |                |         |
+------------------------------------------+----------------+---------+
| 2\. Barbiturates: Mephobarbital          | \|\_\_\_       | \|\_\   |
| (Mebacut); and pentobarbital sodium      | \_\|\_\_\_\_\| | _\_\_\| |
| (Nembutal)                               |                |         |
+------------------------------------------+----------------+---------+
| 3\. Non-prescription GHB (known as       | \|\_\_\_       | \|\_\   |
| Grievous Bodily Harm; Liquid Ecstasy;    | \_\|\_\_\_\_\| | _\_\_\| |
| and Georgia Home Boy)                    |                |         |
+------------------------------------------+----------------+---------+
| 4\. Ketamine (known as Special K or      | \|\_\_\_       | \|\_\   |
| Vitamin K)                               | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 5\. Other tranquilizers, downers,        | \|\_\_\_       | \|\_\   |
| sedatives or hypnotics                   | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| h\. Inhalants (poppers, snappers, rush,  | \|\_\_\_       | \|\_\   |
| whippets)                                | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| i\. Other illegal drugs (Specify)        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+

**3. In the past 30 days have you injected drugs?**

YES

NO

Refused

Don't know

***\[IF NO, REFUSED, OR DON'T KNOW GO TO SECTION C.\]***

**4. In the past 30 days, how often did you use a syringe/needle,
cooker, cotton or water that someone else used?**

Always

More than half the time

Half the time

Less than half the time

Never

Refused

Don't know

C. FAMILY AND LIVING CONDITIONS

**1. In the past 30 days, where have you been living most of the time?
*\[DO NOT READ RESPONSE OPTIONS TO CLIENT.\]***

Shelter (safe havens, transitional living center \[TLC\], low demand
facilities, reception centers, other temporary day or evening facility)

Street/outdoors (sidewalk, doorway, park, public or abandoned building)

Institution (hospital, nursing home, jail/prison)

Housed:

Own/rent apartment, room, or house

Someone else's apartment, room or house

Halfway house

Residential treatment

Other housed (Specify)

Refused

Don't know

**2. During the past 30 days, how stressful have things been for you
because of your use of alcohol or other drugs?**

Not at all

Somewhat

Considerably

Extremely

Not Applicable

Refused

Don't know

**3. During the past 30 days, has your use of alcohol or other drugs
caused you to reduce or give up important activities?**

Not at all

Somewhat

Considerably

Extremely

Not Applicable

Refused

Don't know

C. FAMILY AND LIVING CONDITIONS (Continued)

**4. During the past 30 days, has your use of alcohol or other drugs
caused you to have emotional problems?**

Not at all

Somewhat

Considerably

Extremely

Not Applicable

Refused

Don't know

**5. *\[IF NOT MALE,\]* Are you currently pregnant?**

Yes

No

Refused

Don't know

**6. Do you have children?**

Yes

No

Refused

Don't know

***\[IF NO, REFUSED, OR DON'T KNOW GO TO SECTION D.\]***

**a. How many children do you have?**

\|\_\_\_\_\|\_\_\_\_\|   Refused   Don't know

**b. Are any of your children living with someone else due to a child
protection court order?**

Yes

No

Refused

Don't know

***\[IF NO, REFUSED, OR DON'T KNOW GO TO SECTION D.\]***

**c. *\[IF YES,\]* How many of your children are living with someone
else due to a child protection court order?**

\|\_\_\_\_\|\_\_\_\_\|   Refused   Don't know

C. FAMILY AND LIVING CONDITIONS (Continued)

**d. For how many of your children have you lost parental rights? *\[THE
CLIENT'S PARENTAL RIGHTS WERE TERMINATED.\]***

\|\_\_\_\_\|\_\_\_\_\|   Refused   Don't know

D. EDUCATION, EMPLOYMENT, AND INCOME

**1. Are you currently enrolled in school or a job training program?
*\[IF ENROLLED,\]* Is that full time or part time?**

Not enrolled

Enrolled, full time

Enrolled, part time

Other (Specify)

Refused

Don't know

**2. What is the highest level of education you have finished, whether
or not you received a degree?**

 NEVER ATTENDED

 1^ST^ GRADE

 2^ND^ GRADE

 3^RD^ GRADE

 4^TH^ GRADE

 5^TH^ GRADE

 6^TH^ GRADE

-   7^TH^ GRADE

-   8^TH^ GRADE

-   9^TH^ GRADE

-   10^TH^ GRADE

-   11^TH^ GRADE

-   12^TH^ GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT

-   COLLEGE OR UNIVERSITY/1^st^ YEAR COMPLETED

-   COLLEGE OR UNIVERSITY/2^nd^ YEAR COMPLETED/ASSOCIATES DEGREE (AA,
    AS)

-   COLLEGE OR UNIVERSITY/3^rd^ YEAR COMPLETED

-   BACHELOR'S DEGREE (BA, BS) OR HIGHER

-   VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH DIPLOMA

-   VOC/TECH DIPLOMA AFTER HIGH SCHOOL

 Refused

 Don't know

D. EDUCATION, EMPLOYMENT, AND INCOME (Continued)

**3. Are you currently employed? *\[CLARIFY BY FOCUSING ON STATUS DURING
MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER CLIENT WORKED AT ALL OR
HAD A REGULAR JOB BUT WAS OFF WORK.\]***

 Employed full time (35+ hours per week, or would have been )

 Employed part time

 Unemployed, looking for work

 Unemployed, disabled

 Unemployed, volunteer work

 Unemployed, retired

 Unemployed, not looking for work

 Other (Specify)

 Refused

 Don't know

**4. Approximately, how much money did YOU receive (pre-tax individual
income) in the past 30 days from...**

**RF DK**

a\. Wages \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|      

b\. Public assistance \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|    

c\. Retirement \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|       

d\. Disability \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|      

e\. Non-legal income \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|   
  

f\. Family and/or friends \$ \|\_\_\|\_\_\|\_\_\| ,
\|\_\_\|\_\_\|\_\_\|      

g\. Other (Specify) \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|   
   

E. CRIME AND CRIMINAL JUSTICE STATUS

**1. In the past 30 days, how many times have you been arrested?**

\|\_\_\_\_\|\_\_\_\_\| times   Refused   Don't know

***\[IF NO ARRESTS, GO TO ITEM E3.\]***

**2. In the past 30 days, how many times have you been arrested for
drug-related offenses?**

\|\_\_\_\_\|\_\_\_\_\| times   Refused   Don't know

**3. In the past 30 days, how many nights have you spent in
jail/prison?**

\|\_\_\_\_\|\_\_\_\_\| nights   Refused   Don't know

E. CRIME AND CRIMINAL JUSTICE STATUS (Continued)

**4. In the past 30 days, how many times have you committed a crime?
*\[CHECK NUMBER OF DAYS USED ILLEGAL DRUGS IN ITEM B1c ON PAGE 4. ANSWER
HERE IN E4 MUST BE EQUAL TO OR GREATER THAN NUMBER IN B1c BECAUSE USING
ILLEGAL DRUGS IS A CRIME.\]***

\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\| times   Refused   Don't know

**5. Are you currently awaiting charges, trial, or sentencing?**

 Yes

 No

Refused

Don't know

**6. Are you currently on parole or probation?**

 Yes

 No

Refused

Don't know

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

**1. How would you rate your overall health right now?**

Excellent

Very good

Good

Fair

Poor

Refused

Don't know

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (Cont.)

**2. During the past 30 days, did you receive:**

+---------------------------------+----+----------------+----+---+----+
| **a. Inpatient Treatment for:** |    | ***\[IF        |    |   |    |
|                                 |    | YES\]***       |    |   |    |
+---------------------------------+----+----------------+----+---+----+
|                                 | *  | **Altogether\  | ** | * | ** |
|                                 | *Y | for how many   | NO | * | DK |
|                                 | ES | nights**       | ** | R | ** |
|                                 | ** |                |    | F |    |
|                                 |    |                |    | * |    |
|                                 |    |                |    | * |    |
+---------------------------------+----+----------------+----+---+----+
| > i\. Physical complaint        |    | nights         |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > ii\. Mental or emotional      |    | nights         |    |   |    |
| > difficulties                  |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > iii\. Alcohol or substance    |    | nights         |    |   |    |
| > abuse                         |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+

+---------------------------------+----+----------------+----+---+----+
| **b. Outpatient Treatment       |    | ***\[IF        |    |   |    |
| for:**                          |    | YES\]***       |    |   |    |
+---------------------------------+----+----------------+----+---+----+
|                                 | *  | **Altogether\  | ** | * | ** |
|                                 | *Y | for how many   | NO | * | DK |
|                                 | ES | times**        | ** | R | ** |
|                                 | ** |                |    | F |    |
|                                 |    |                |    | * |    |
|                                 |    |                |    | * |    |
+---------------------------------+----+----------------+----+---+----+
| > i\. Physical complaint        |    | times          |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > ii\. Mental or emotional      |    | times          |    |   |    |
| > difficulties                  |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > iii\. Alcohol or substance    |    | times          |    |   |    |
| > abuse                         |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+

+---------------------------------+----+----------------+----+---+----+
| **c. Emergency Room Treatment   |    | ***\[IF        |    |   |    |
| for:**                          |    | YES\]***       |    |   |    |
+---------------------------------+----+----------------+----+---+----+
|                                 | *  | **Altogether\  | ** | * | ** |
|                                 | *Y | for how many   | NO | * | DK |
|                                 | ES | times**        | ** | R | ** |
|                                 | ** |                |    | F |    |
|                                 |    |                |    | * |    |
|                                 |    |                |    | * |    |
+---------------------------------+----+----------------+----+---+----+
| > i\. Physical complaint        |    | times          |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > ii\. Mental or emotional      |    | times          |    |   |    |
| > difficulties                  |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > iii\. Alcohol or substance    |    | times          |    |   |    |
| > abuse                         |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (Cont.)

**3. During the past 30 days, did you engage in sexual activity?**

Yes

No **→ *\[GO TO F4.\]***

Not permitted to ask **→ *\[GO TO F4.\]***

Refused **→ *\[GO TO F4.\]***

Don't know **→ *\[GO TO F4.\]***

***\[IF YES\]* Altogether, how many:**

+-----------------------------------------------+-------------+---+----+
|                                               | *           | * | ** |
|                                               | *Contacts** | * | DK |
|                                               |             | R | ** |
|                                               |             | F |    |
|                                               |             | * |    |
|                                               |             | * |    |
+-----------------------------------------------+-------------+---+----+
| a\. Sexual contacts (vaginal, oral, or anal)  | \|\_\_\_\_  |  |   |
| did you have?                                 | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| b\. Unprotected sexual contacts did you have? | \|\_\_\_\_  |  |   |
| ***\[IF ZERO, GO TO F4.\]***                  | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| c\. Unprotected sexual contacts were with an  |             |   |    |
| individual who is or was:                     |             |   |    |
+-----------------------------------------------+-------------+---+----+
| > 1\. HIV positive or has AIDS                | \|\_\_\_\_  |  |   |
|                                               | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| > 2\. An injection drug user                  | \|\_\_\_\_  |  |   |
|                                               | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| > 3\. High on some substance                  | \|\_\_\_\_  |  |   |
|                                               | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+

**4. In the past 30 days, not due to your use of alcohol or drugs, how
many days have you:**

  ----------------------------------------------- ------------------------ -------- --------
                                                  **Days**                 **RF**   **DK**

  a\. Experienced serious depression              \|\_\_\_\_\|\_\_\_\_\|           

  b\. Experienced serious anxiety or tension      \|\_\_\_\_\|\_\_\_\_\|           

  c\. Experienced hallucinations                  \|\_\_\_\_\|\_\_\_\_\|           

  d\. Experienced trouble understanding,          \|\_\_\_\_\|\_\_\_\_\|           
  concentrating, or remembering                                                     

  e\. Experienced trouble controlling violent     \|\_\_\_\_\|\_\_\_\_\|           
  behavior                                                                          

  f\. Attempted suicide                           \|\_\_\_\_\|\_\_\_\_\|           

  g\. Been prescribed medication for              \|\_\_\_\_\|\_\_\_\_\|           
  psychological/emotional problem                                                   
  ----------------------------------------------- ------------------------ -------- --------

***\[IF CLIENT REPORTS ZERO DAYS TO ALL ITEMS IN QUESTION 4, SKIP TO
SECTION G.\]***

**5. How much have you been bothered by these psychological or emotional
problems in the past 30 days?**

Not at all

Slightly

Moderately

Considerably

Extremely

Refused

Don't know

G. SOCIAL CONNECTEDNESS

**1. In the past 30 days, did you attend any voluntary self-help groups
for recovery that were not affiliated with a religious or faith-based
organization? In other words, did you participate in a non-professional,
peer-operated organization that is devoted to helping individuals who
have addiction related problems such as: Alcoholics Anonymous, Narcotics
Anonymous, Oxford House, Secular Organization for Sobriety, or Women for
Sobriety, etc.**

Yes  ***\[IF YES\]*** Specify how many times
[   ]{.underline}  Refused   Don't know

No

Refused

Don't know

**2. In the past 30 days, did you attend any religious/faith affiliated
recovery self-help groups?**

Yes  ***\[IF YES\]*** Specify how many times
[   ]{.underline}  Refused   Don't know

No

Refused

Don't know

**3. In the past 30 days, did you attend meetings of organizations that
support recovery other than the organizations described above?**

Yes  ***\[IF YES\]*** Specify how many times
[   ]{.underline}  Refused   Don't know

No

Refused

Don't know

**4. In the past 30 days, did you have interaction with family and/or
friends that are supportive of your recovery?**

Yes

No

Refused

Don't know

5.  **To whom do you turn when you are having trouble? *\[SELECT ONLY
    ONE.\]***

No One

Clergy Member

Family Member

Friends

REFUSED

DoN'T KNOW

Other Specify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***\[IF THIS IS AN INTAKE/BASELINE INTERVIEW, STOP NOW, THE INTERVIEW IS
COMPETE. REMEMBER TO FILL IN PLANNED SERVICES ON PAGE 2.\]***

I. FOLLOW-UP STATUS

\[*REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP\]*

**1. What is the follow-up status of the client? *\[THIS IS A REQUIRED
FIELD: NA, REFUSED, DON'T KNOW, AND MISSING WILL NOT BE ACCEPTED\]. ***

01 = Deceased at time of due date

11 = Completed interview within specified window

12 = Completed interview outside specified window

21 = Located, but refused, unspecified

22 = Located, but unable to gain institutional access

23 = Located, but otherwise unable to gain access

24 = Located, but withdrawn from project

31 = Unable to locate, moved

32 = Unable to locate, other (SPECIFY)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2. Is the client still receiving services from your program?**

Yes

No

***\[IF THIS IS A FOLLOW-UP INTERVIEW STOP NOW, THE INTERVIEW IS
COMPLETE.\]***

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) \|\_\_\_\|\_\_\_\|\_\_\_\|

+-----------------------------------------------------------------------+
| ### Appendix J                                                        |
|                                                                       |
| Number range CHAPTERForm Approved                                     |
|                                                                       |
| OMB No. 0930-0266                                                     |
|                                                                       |
| Expiration Date 05/31/2008                                            |
|                                                                       |
| **VOUCHER INFORMATION**                                               |
|                                                                       |
| **ACCESS TO RECOVERY PROGRAM**                                        |
|                                                                       |
| Public reporting burden for this collection of information is         |
| estimated to average 2 minutes per response including the time for    |
| reviewing instructions, searching existing data sources, gathering    |
| and maintaining the data needed, and completing and reviewing the     |
| collection of information. Send comments regarding this burden        |
| estimate or any other aspect of this collection of information 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 0930-0266..                                |
+-----------------------------------------------------------------------+

voucher information

Client ID: **\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_**

Grant ID: **\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_**

Voucher ID: **\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_**

Voucher Issue Date: \|\_\_\_\|\_\_\_\| / \|\_\_\_\|\_\_\_\| /
\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|

Month Day Year

Voucher Amount:: \$**\_\_ \_\_ \_\_ \_\_ \_\_. \_\_ \_\_**

Voucher Service Type: (Check all that apply)

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

  --------------------- --------------------------------- ---------------------- --------------------------------
  **Clinical Treatment                                    **Medical Services**   
  Services**                                                                     

                                                                                 

                        1\. Screening/assessment                                 21\. Medical Care

                        2\. Brief Intervention                                   22\. Alcohol/Drug Testing

                        3\. Treatment Planning                                   23\. HIV/AIDS Medical Support &
                                                                                 Testing

                        4\. Individual Counseling                                24\. Other Medical Services

                        5\. Group Counseling              **After Care/Recovery  
                                                          Support Services**     

                        6\. Family/Marriage Counseling                           

                        7\. Co-occurring Treatment                               25\. Continuing Care
                        Services                                                 

                        8\. Pharmacological Interventions                        26\. Relapse prevention

                        9\. HIV/AIDS Counseling                                  27\. Recovery Coaching

                        10\. Other Clinical Services                             28\. Self-help and Support
                                                                                 Groups

  **Case                                                                         29\. Spiritual Support
  Management/Recovery                                                            
  Support Services**                                                             

                                                                                 30\. Other After Care Services

                        11\. Family Services (including   **Education/Recovery   
                        marriage education, parenting and Support Services**     
                        child development services)                              

                        12\. Child Care                                          31\. Substance Abuse Education

                        13\. Employment Services                                 32\. HIV/AIDS Education

                        14\. Pre-employment Services                             33\. Other Education Services

                        15\. Employment Coaching          **Peer-to-Peer         
                                                          Recovery Support       
                                                          Services**             

                        16\. Individual Services                                 
                        Coordination                                             

                        17\. Transportation                                      34\. Peer Coaching or Mentoring

                        18\. HIV/AIDS services                                   35\. Housing Support

                        19\. Supportive transitional                             36\. Alcohol- and Drug-Free
                        drug-free housing services                               Social Activities

                        20\. Other Case Management                               37\. Information and Referral
                        Services                                                 

                                                                                 38\. Other Peer-to-Peer Recovery
                                                                                 Support Services
  --------------------- --------------------------------- ---------------------- --------------------------------

+-----------------------------------------------------------------------+
| ### Appendix K                                                        |
|                                                                       |
| Number range CHAPTERForm Approved                                     |
|                                                                       |
| OMB No. 0930-0266                                                     |
|                                                                       |
| Expiration Date 05/31/2008                                            |
|                                                                       |
| **VOUCHER TRANSACTION INFORMATION**                                   |
|                                                                       |
| **ACCESS TO RECOVERY PROGRAM**                                        |
|                                                                       |
| Public reporting burden for this collection of information is         |
| estimated to average 2 minutes per response including the time for    |
| reviewing instructions, searching existing data sources, gathering    |
| and maintaining the data needed, and completing and reviewing the     |
| collection of information. Send comments regarding this burden        |
| estimate or any other aspect of this collection of information 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 0930-0266.                                 |
+-----------------------------------------------------------------------+

voucher TRANSACTION information

Client ID: **\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_**

Grant ID: **\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_**

Voucher ID: **\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_**

Transaction ID: \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_

Provider ID: \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_

Voucher Redemption Date: \|\_\_\_\|\_\_\_\| / \|\_\_\_\|\_\_\_\| /
\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|

Month Day Year

Amount Redeemed: \$\_\_ \_\_ \_\_ \_\_ \_\_.\_\_ \_\_

Number of Sessions: \_\_ \_\_ \_\_ \_\_ \_\_

Voucher Service Type: (Indicate which service the client received for
this transaction from the list below)

  --------------------- ---------------------------------- ---------------------- -------------------------------
  **Clinical Treatment                                     **Medical Services**   
  Services**                                                                      

                                                                                  

                        1\. Screening/assessment                                  21\. Medical Care

                        2\. Brief Intervention                                    22\. Alcohol/Drug Testing

                        3\. Treatment Planning                                    23\. HIV/AIDS Medical Support &
                                                                                  Testing

                        4\. Individual Counseling                                 24\. Other Medical Services

                        5\. Group Counseling               **After Care/Recovery  
                                                           Support Services**     

                        6\. Family/Marriage Counseling                            

                        7\. Co-occurring Treatment                                25\. Continuing Care
                        Services                                                  

                        8\. Pharmacological Interventions                         26\. Relapse prevention

                        9\. HIV/AIDS Counseling                                   27\. Recovery Coaching

                        10\. Other Clinical Services                              28\. Self-help and Support
                                                                                  Groups

  **Case                                                                          29\. Spiritual Support
  Management/Recovery                                                             
  Support Services**                                                              

                                                                                  30\. Other After Care Services

                        11\. Family Services (including    **Education/Recovery   
                        marriage education, parenting and  Support Services**     
                        child development services)                               

                        12\. Child Care                                           31\. Substance Abuse Education

                        13\. Employment Services                                  32\. HIV/AIDS Education

                        14\. Pre-employment Services                              33\. Other Education Services

                        15\. Employment Coaching           **Peer-to-Peer         
                                                           Recovery Support       
                                                           Services**             

                        16\. Individual Services                                  
                        Coordination                                              

                        17\. Transportation                                       34\. Peer Coaching or Mentoring

                        18\. HIV/AIDS services                                    35\. Housing Support

                        19\. Supportive transitional                              36\. Alcohol- and Drug-Free
                        drug-free housing services                                Social Activities

                        20\. Other Case Management                                37\. Information and Referral
                        Services                                                  

                                                                                  38\. Other Peer-to-Peer
                                                                                  Recovery Support Services
  --------------------- ---------------------------------- ---------------------- -------------------------------

## Appendix L: Confidentiality and Participant Protection {#appendix-l-confidentiality-and-participant-protection .unnumbered}

Because of the confidential nature of the work in which many SAMHSA
grantees are involved, it is important to have safeguards protecting
individuals from risks associated with their participation in SAMHSA
projects. All applicants must address the seven bullets below. If some
are not applicable or relevant to the proposed project, simply state
that they are not applicable and indicate why. In addition to addressing
these seven bullets, read the section that follows entitled Protection
of Human Subjects Regulations to determine if the regulations may apply
to your project. If so, you are required to describe the process you
will follow for obtaining IRB approval. While we encourage you to keep
your responses brief, there are no page limits for this section and no
points will be assigned by the Review Committee. Problems with
confidentiality, participant protection, and protection of human
subjects identified during peer review of the application may result in
the delay of funding.

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

-   Identify and describe any foreseeable physical, medical,
    psychological, social, and legal risks or potential adverse effects
    as a result of the project itself or any data collection activity.

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-   Describe the procedures you will follow to minimize or protect
    participants against potential risks, **including risks to
    confidentiality**.

-   Identify plans to provide guidance and assistance in the event there
    are adverse effects to participants.

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

2.  *[Fair Selection of Participants]{.underline}*

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

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

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

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

3.  *[Absence of Coercion]{.underline}*

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

-   If you plan to compensate participants, state how participants will
    be awarded incentives (e.g., money, gifts, etc.).

-   State how volunteer participants will be told that they may receive
    services intervention even if they do not participate in or complete
    the data collection component of the project.

4.  *[Data Collection]{.underline}*

-   Identify from whom you will collect data (e.g., from participants
    themselves, family members, teachers, others). Describe the data
    collection procedures and specify the sources for obtaining data
    (e.g., school records, interviews, psychological assessments,
    questionnaires, observation, or other sources). Where data are to be
    collected through observational techniques, questionnaires,
    interviews, or other direct means, describe the data collection
    setting.

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

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

5.  *[Privacy and Confidentiality]{.underline}*

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

-   Describe:

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```
-   How you will use data collection instruments.

-   Where data will be stored.

-   Who will or will not have access to information.

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

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

6.  *[Adequate Consent Procedures]{.underline}*

-   List what information will be given to people who participate in the
    project. Include the type and purpose of their participation.
    Identify the data that will be collected, how the data will be used
    and how you will keep the data private.

-   State:

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```
-   Whether or not their participation is voluntary.

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

-   Possible risks from participation in the project.

-   Plans to protect clients from these risks.

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

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

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```
-   Indicate if you will obtain informed consent from participants or
    assent from minors along with consent from their parents or legal
    guardians. Describe how the consent will be documented. For example:
    Will you read the consent forms? Will you ask prospective
    participants questions to be sure they understand the forms? Will
    you give them copies of what they sign?

-   Include, as appropriate, sample consent forms that provide for: (1)
    informed consent for participation in service intervention; (2)
    informed consent for participation in the data collection component
    of the project; and (3) informed consent for the exchange (releasing
    or requesting) of confidential information. The sample forms must be
    included in **Appendix 3, "Sample Consent Forms"**, of your
    application. If needed, give English translations.

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

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

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

7.  *[Risk/Benefit Discussion]{.underline}*

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

    [Protection of Human Subjects Regulations]{.underline}

Applicants may also have to comply with the Protection of Human Subjects
Regulations (45 CFR 46), depending on the evaluation and data collection
procedures proposed and the population to be served.

Applicants must be aware that even if the Protection of Human Subjects
Regulations do not apply to all projects funded, the specific evaluation
design proposed by the applicant may require compliance with these
regulations.

Applicants whose projects must comply with the Protection of Human
Subjects Regulations must describe the process for obtaining
Institutional Review Board (IRB) approval fully in their applications.
While IRB approval is not required at the time of grant award, these
applicants will be required, as a condition of award, to provide the
documentation that an Assurance of Compliance is on file with the Office
for Human Research Protections (OHRP) and that IRB approval has been
received prior to enrolling any clients in the proposed project.

General information about Protection of Human Subjects Regulations can
be obtained on the web at <http://www.hhs.gov/ohrp>. You may also
contact OHRP by e-mail (<ohrp@osophs.dhhs.gov>[)]{.underline} or by
phone (240/453-6900). SAMHSA-specific questions related to Protection of
Human Subjects Regulations should be directed to the program contact
listed in Section VII of this RFA.

### Appendix M: Access to Recovery Performance Targets

+------------------------------------------+--------+--------+---------+
| **Long Term Goal:** See CSAT/Capacity    |        |        |         |
+------------------------------------------+--------+--------+---------+
| **Measures**                             | **FY** | **Ta   | **R     |
|                                          |        | rget** | esult** |
+------------------------------------------+--------+--------+---------+
| Increase the number of clients gaining   | *2010* | 55,000 | Nov-10  |
| access to treatment *(output)* ^1^       |        |        |         |
+------------------------------------------+--------+--------+---------+
|                                          | *2009* | 55,000 | Nov-09  |
+------------------------------------------+--------+--------+---------+
|                                          | *2008* | 25,000 | Nov-08  |
+------------------------------------------+--------+--------+---------+
|                                          | *2007* | 50,000 | Dec-07  |
+------------------------------------------+--------+--------+---------+
|                                          | *2006* | 50,000 | 96,959  |
+------------------------------------------+--------+--------+---------+
|                                          | *2005* | Ba     | 23,138  |
|                                          |        | seline |         |
+------------------------------------------+--------+--------+---------+
| Increase the percentage of adults        | *2010* | Sep-07 | Nov-10  |
| receiving services who: *(outcome)*      |        |        |         |
|                                          |        |        |         |
| a\) had no past month substance use      |        |        |         |
+------------------------------------------+--------+--------+---------+
|                                          | *2009* | Sep-07 | Nov-09  |
+------------------------------------------+--------+--------+---------+
|                                          | *2008* | Sep-07 | Nov-08  |
+------------------------------------------+--------+--------+---------+
|                                          | *2007* | 81%    | Dec-07  |
+------------------------------------------+--------+--------+---------+
|                                          | *2006* | 79%    | 81.4%   |
+------------------------------------------+--------+--------+---------+
|                                          | *2005* | Ba     | 78%     |
|                                          |        | seline |         |
+------------------------------------------+--------+--------+---------+
| b\) had improved family and living       | *2010* | Sep-07 | Nov-10  |
| conditions                               |        |        |         |
+------------------------------------------+--------+--------+---------+
|                                          | *2009* | Sep-07 | Nov-09  |
+------------------------------------------+--------+--------+---------+
|                                          | *2008* | Sep-07 | Nov-08  |
+------------------------------------------+--------+--------+---------+
|                                          | *2007* | 52%%   | Dec-07  |
+------------------------------------------+--------+--------+---------+
|                                          | *2006* | 63%    | 51%     |
+------------------------------------------+--------+--------+---------+
|                                          | *2005* | Ba     | 62%     |
|                                          |        | seline |         |
+------------------------------------------+--------+--------+---------+

  ------------------------------------------ --------- ---------- ----------
  c\) had no/reduced involvement with the    *2010*    Sep-07     Nov-10
  criminal justice system                                         

                                             *2009*    Sep-07     Nov-09

                                             *2008*    Sep-07     Nov-08

                                             *2007*    97%        Dec-07

                                             *2006*    95%        96.8%

                                             *2005*    Baseline   95%

  d\) had improved social support            *2010*    Sep-07     Nov-10

                                             *2009*    Sep-07     Nov-09

                                             *2008*    Sep-07     Nov-08

                                             *2007*    90%        Dec-07

                                             *2006*    90%        90%

                                             *2005*    Baseline   89%

  e\) were currently employed or engaged in  *2010*    Sep-07     Nov-10
  productive activities                                           

                                             *2009*    Sep-07     Nov-09

                                             *2008*    Sep-07     Nov-08

                                             *2007*    50%        Dec-07

                                             *2006*    57%        50%

                                             *2005*    Baseline   56%

  f\) had improved retention in treatment    *2010*    Sep-07     Nov-10

                                             *2009*    Sep-07     Nov-09

                                             *2008*    Sep-07     Nov-08

                                             *2007*    31%        Dec-07

                                             *2006*    24%        30.2%

                                             *2005*    Baseline   22.8%

  **Data Source:** CSAT\'s Automated                              
  Services Accountability Improvement System                      
  (SAIS)                                                          
  ------------------------------------------ --------- ---------- ----------

  -----------------------------------------------------------------------
  **Data Validation:** All data are automatically checked as they are
  input into SAIS.  Validation and verification checks are run on the
  data as they are being entered.  The system will not allow any data
  that are out of range or violate skip patterns to be saved into the
  database.

  **Cross Reference:** HHS #1.4; Secretary's 500 day plan: Increasing the
  commitment to faith-and community-based grants, including Access to
  Recovery.
  -----------------------------------------------------------------------

\* Initial Access to Recovery grants were made in August 2004, close to
the end of FY 2004. Services are not necessarily provided in the same
year Federal funds are obligated. Thus, although the baseline reported
for FY 2005 will represent people served in FY 2005, most of the funding
will consist of FY 2004 dollars. With the FY 2004 grants, an estimated
125,000 clients will be served over the three year grant period.

1\. The first cohort of grantees ends in FY 2007. The second cohort of
ATR grantees will begin in FY 2008. Targets for 2008 are lower to allow
the new grantees to develop the appropriate infrastructure.

[^1]: Indirect funding means that individual, private choice, rather
    than the Government, determines which substance abuse service
    provider eventually receives the funds. With indirect funding, the
    individual in need of the service is given a voucher, coupon,
    certificate, or other means of free agency, such that he or she has
    the power to select for himself or herself from among eligible
    substance abuse service providers, whereupon the voucher (or other
    method of payment) may be "redeemed" for the service rendered. Under
    "direct" funding, the Government or an intermediate organization
    with the same duties as a governmental entity purchases the needed
    services directly from the substance abuse service provider. Under
    this scenario, there are no intervening steps in which the client's
    choice comes into play. The government or intermediate organization
    selects the provider from which the client will receive services.

[^2]: Several performance measures will be reported for all providers,
    grass-roots providers, providers identified as faith-based and
    providers identified as secular. Grantees will receive training on
    how to provide this information using the provider ID number
    included in the Voucher Information Tool and Voucher Transaction
    Tool. The categories of providers are not mutually exclusive. That
    is, grass-roots providers are all providers with an annual operating
    budget of \$500,000 or less; they may be faith-based or secular.
    Faith-based and secular providers may have operating budgets that
    exceed \$500,000 per year.

[^3]: The follow-up rate must be at least 80 percent of the number of
    clients actually served.

[^4]: Following the initial award, the Governor may delegate
    responsibility of the ATR project, including signatory authority for
    continuation applications, to a State Agency or State official.