101

Block Grant Reporting Section 

FY 2014

CFDA 93.958 

(Mental Health)

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration
102

Table of Contents

A. Introduction

B. Implementation Report

MHBG Table 1 Priority Area and Annual Performance Indicators – Progress Report

C. State Agency Expenditure Reports

MHBG Table 2 (URS Table 7) State Agency Expenditure Report

MHBG Table 3 MHBG Expenditures by Service

MHBG Table 4 Set-aside for Children’s Mental Health Services

MHBG Table 5 (URS Table 8) Profile Of Mental Health Block Grant Expenditures for

Non-Direct Service Activities. 

MHBG Table 6 (URS Table 10) – Statewide Entity Inventory

MHBG Table 7 Maintenance of Effort for Statewide Expenditures on Mental Health 

Services

D. Population and Services Reports

MHBG Table 8A and MHBG Table 8b Profile of Clients by Type of Funding Support 

(URS Tables 5A and 5B)

MHBG Table 9 (URS Table 1) Profile of the State Population by Diagnosis. 

MHBG Table 10 (URS Table 12) State Mental Health Agency Profile. 

MHBG Table 11A and MHBG Table 11B (URS Tables 2A and 2B) Profile of Persons 

Served, All Programs by Age, Gender and Race/Ethnicity

MHBG Table 12 (URS Table 3) Profile of Persons Served In the Community Mental 

Health Settings, State Psychiatric Hospitals and Other Settings

MHBG Tables 13A, 13B and 13C (NEW, URS Tables 14A and 14B) Profile of Persons 

with SMI/SED Served By Age, Gender and Race/Ethnicity

MHBG Table 14 (URS Table 5) Profile of Client Turnover; Performance Indicators and 

Accomplishments

E: Performance Indicators and Accomplishments

MHBG Table 15 (URS Table 17) Profile of Adults with Serious Mental Illnesses 

Receiving Specific Services during the Year

MHBG Table 16A (URS Table 4) Profile of Adult Clients by Employment Status

MHBG Table 16B (URS Table 4A) Profile of Adult Clients by Employment Status: By 

Primary Diagnosis Reported

MHBG Table 17 (URS Table 15) Living Situation Profile
103

MHBG Table 18 (URS Table 19B) Profile of Change in School Attendance

MHBG Table 19 (URS Table 9) Social Connectedness and Improved Functioning

MHBG Table 20A (URS Table 11) Summary Profile of Client Evaluation of Care

MHBG Table 20B (URS Table 11A) Consumer Evaluation of Care by Consumer 

Characteristics: Race/Ethnicity

MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice 

Involvement

MHBG Table 22 (URS Table 16) Profile of Adults with Serious Mental Illnesses and

Children with Serious Emotional Disturbances Receiving Specific Services

MHBG Table 23A (URS Table 20A) Profile of Non-Forensic (Voluntary and CivilInvoluntary) Patients Readmission to Any State Psychiatric Inpatient Hospital within 

30/180 Days of Discharge 

MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to Any 

State Psychiatric Inpatient Hospital within 30/180 Days of Discharge 

MHBG Table 24 (URS Table 21) Profile of Non-Forensic (Voluntary and CivilInvoluntary Patients) Readmission to Any Psychiatric Inpatient Care Unit (State Operated 

or Other Psychiatric Inpatient Unit) within 30/180 Days of Discharge 
104

Section A. Introduction

Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. 300x-52(a)) requires the 

Secretary of the Department of Health and Human Services, acting through the Administrator of the 

Substance Abuse and Mental Health Services Administration (SAMHSA), to determine the extent to 

which States and Jurisdictions have implemented the State plan for the prior fiscal year. The purpose 

of the Annual Report is to provide information to assist the Secretary in making this determination. 

States and Jurisdictions are requested to prepare and submit their reports for the last completed State 

Fiscal Year (SFY) in the format provided in this guidance. The report will address the purposes for 

which the MHBG were expended, the recipients of grant funds, and the authorized activities 

conducted and services purchased with such funds. Particular attention should be given to the 

progress made toward accomplishing the goals and performance indicators identified in the States’ 

and Jurisdictions’ plans. 

All States and Jurisdictions are required to prepare and submit their respective reports utilizing 

SAMHSA’s Web Block Grant Application System (BGAS). This report must be received by 

SAMHSA not later than December 1 in order for the State or Jurisdiction to receive its next grant. If 

the due date falls on a weekend or Federal holiday, the report will be due on the next business day. 

The following schedule includes specific due dates for annual reports:

Plan and Report Due Dates

Application for 

Federal Fiscal Year

Plan Due

Date

Planning Period Report Due

Date

Reporting Period

2014 09/03/2013 07/01/2013 -

06/30/2015

12/02/2013 Last Completed 

SFY

2015 12/01/2014 Last Completed 

SFY

States and Jurisdictions are required to complete the Reporting Document. The Reporting Document 

is comprised of the following sections:

Section B: Implementation Report - In this section, States and Jurisdictions are required to provide a 

brief review of the extent to which their respective plans were implemented, the progress towards the 

priorities and goals identified in the Block Grant plan covering the last completed fiscal year. The 

report should also include a brief review of areas that the State or Jurisdiction identified in that Block 

Grant Plan as needing improvement and changes that the State or Jurisdiction would propose to 

achieve the goals established for the priorities. 

Section C: State Agency Expenditure Reports - In this section, States and Jurisdictions should 

provide information regarding expenditures for authorized activities and services for mental health. 
105

Section D: Populations and Services Report - In this section, States and Jurisdictions must provide 

specific information regarding the number of individuals that were served with MHBG funds. In 

addition, States and Jurisdictions should provide specific information regarding the services these 

individuals received. 

Section E: Performance Indicators and Accomplishments - In this section of the report, States and 

Jurisdictions are required to complete the Performance Indicator tables. Performance indicators 

should be reported using the table format provided in this document. The purpose of the 

performance indicator tables is to show progress made over time as measured by SAMHSA’s 

National Outcome Measures (NOMS) for mental health services as well as any State- or Jurisdictionselected performance indicators. 
106

B. Implementation Report 

The information States and Jurisdictions entered into the performance indicator tables (Plan Table 1) 

in the planning section of the 2014/2015 Behavioral Health Assessment and Plan will automatically 

populate cells 1 – 6 in the progress report tables below. States and Jurisdictions are required to 

indicate whether each first-year performance target/outcome measurement identified in the 

2014/2015 Plan was “Achieved” or “Not Achieved” in Cell 7, Report of Progress toward goal 

attainment. If a target was not achieved, a detailed explanation must be provided as well as the 

remedial steps proposed to meet the target.

MHBG Table 1 - Priority Area and Annual Performance Indicators – Progress Report

Priority Areas and Annual Performance Indicators

1. Priority Area: 2.Priority Type (SAP, SAT, MHP, MHS):

3. Population(s) (SMI, SED, PWWDC, IVDUs, HIV EIS, TB, OTHER): 

4. Goal of the priority area:

5. Strategies to attain the goal:

6. Annual Performance Indicators to measure goal success:

Indicator #1:

a) Baseline measurement (Initial data collected prior to the first-year target/outcome): 

b) First-year target/outcome measurement (Progress – end of SFY 2014):

c) Second-year target/outcome measurement (Final – end of SFY 2015):

d) Data source: 

e) Description of data:

f) Data issues/caveats that affect outcome measures:

7. Report of Progress toward Goal Attainment:

First-year Target: ____ Achieved _____ Not Achieved (If not achieved, explain why.) 

Reason why target was not achieved, and changes proposed to meet target:
107

C. State Agency Expenditure Reports 

States and Jurisdictions should provide information regarding MHBG and State funds expended for 

authorized activities to prevent and treat mental illness during the last completed State fiscal year

(SFY). Please complete the tables described below. Please Note: Data for all tables contained in the 

Uniform Reporting System (URS) will continue to be submitted into the URS data base maintained 

by the URS Contractor. Please complete the tables described below.

MHBG Table 2 (URS Table 7) - State Agency Expenditure Report MHBG Table 2 provides 

information on Mental Health Expenditures and Sources of Funding. This includes funding from 

Medicaid, the MHBG and other federal funding sources, state, local and other funds. 

MHBG Table 3 - MHBG Expenditures by Service MHBG Table 3 is to be used to report MHBG 

expenditures by unduplicated individual and specific services.

MHBG Table 4 - Set-aside for Children’s Mental Health Service This table provides a report of 

state-wide expenditures for children’s mental health services during the last completed State fiscal 

year (SFY). 

MHBG Table 5 (URS Table 8) - Profile of Mental Health Block Grant Expenditures for Non-Direct 

Service Activities MHBG Table 5 is used to report expenditures of MHBG funds for non-direct 

service activities that are funded or conducted by the State Mental Health Authority during the last 

completed State fiscal year (SFY).

MHBG Table 6 (URS Table 10) - Statewide Entity Inventory This table reports payments to 

recipients of MHBG funds including intermediaries, e.g., administrative service organizations, and 

other organizations which provided mental health services during the last completed State fiscal year. 

MHBG Table 7 - Maintenance of Effort for Statewide Expenditures for Mental Health Service This 

table reports expenditures of all statewide non-Federal expenditures for authorized activities to 

prevent and treat mental illness during the last completed State fiscal year (SFY). 
108

MHBG Table 2 (URS Table 7) - MHBG State Agency Expenditure Report

This table describes expenditures for public mental health services provided or funded by the State 

mental health agency by source of funding. Include ONLY funds expended by the executive 

branch agency administering the MH Block Grant.

* States may only use MH Block Grant funds to provide primary prevention services to the priority populations of adults 

with serious mental illness and children with serious emotional disturbance.

MHBG State Agency Expenditures Report

MHBG Table 2 

Report Period- From: To:

State Identifier:

Source of Funds

ACTIVITY

(See instructions for using Row 

1.)

A. 

Substance 

Abuse Block 

Grant

B.

Mental 

Health 

Block 

Grant. 

C. Medicaid

(Federal, 

State, and 

local)

D. Other 

Federal Funds 

(e.g., ACF 

(TANF), CDC, 

CMS 

(Medicare) 

SAMHSA, etc.)

E. State 

funds

F. Local 

funds

(excluding 

local

Medicaid)

G. 

Other

1. Substance Abuse 

Prevention and Treatment

$ $ $ $ $ $ $

a. Pregnant Women 

and Women with 

Dependent Children

$ $ $ $ $ $ $

b. All Other $ $ $ $ $ $ $

2. Primary Prevention* $ $ $ $ $ $ $

3. Tuberculosis Services $ $ $ $ $ $ $

4. HIV Early Intervention 

Services

$ $ $ $ $ $ $

5. State Hospital

$

$ $ $ $ $ $

6. Other 24 Hour Care $ $ $ $ $ $ $

7. Ambulatory/Community Non24 Hour Care

$ $ $ $ $ $ $

8. Administration (excluding 

program / provider level

$ $ $ $ $ $ $

9. Total $ $ $ $ $ $ $
109

MHBG Table 3 (Requested) - MH Block Grant Expenditures by Service 

Table 3 is to be used to report MHBG expenditures by unduplicated individual and specific services.

MHBG Block Grant Expenditures by Service

MHBG Table 3 

State Identifier:

Report Period- From: To:

Service

Unduplicated 

Individuals

Unit

Type

Unit

Quantity

MHBG 

Expenditures

Healthcare Home/Physical Health

General and specialized outpatient medical services

Acute Primary care

General Health Screens, Tests and Immunizations

Comprehensive Care Management

Care coordination and Health Promotion

Comprehensive Transitional Care

Individual and Family Support

Referral to Community Services

Prevention and Wellness

Screening, Brief Intervention and Referral to Treatment (SBIRT)

Brief Motivational Interviewing

Screening and Brief Intervention for Tobacco Cessation

Parent Training

Facilitated Referral

Relapse Prevention/Wellness Recovery Support

Warm Line

Engagement Services

Assessment

Specialized Evaluations

Service Planning

Consumer/Family Education

Outreach

Outpatient Services

Individual Evidenced Based Therapies

Group Therapy

Family Therapy 

Multi-family counseling

Consultation with Caregivers

Medication Services

Medication management

Pharmacotherapy

Laboratory Services

Community Support Services

Parent/Caregiver Support

Skill Building

Case management
110

MHBG Block Grant Expenditures by Service

MHBG Table 3 

State Identifier:

Report Period- From: To:

Service

Unduplicated 

Individuals

Unit

Type

Unit

Quantity

MHBG 

Expenditures

Continuing care

Behavior management

Supported employment

Permanent supportive housing

Recovery housing

Therapeutic mentoring

Traditional healing services

Recovery Support Services

Peer Support

Recovery Support Coaching

Recovery Support Center Services

Supports for Self Directed Care

Other Supports

Personal care

Homemaker

Respite

Supported education

Transportation

Assisted Living

Recreational services

Trained Behavioral Health Interpreters

Interactive Communication Technology Devices

Intensive Support Services

Substance Abuse Intensive Outpatient (IOP)

Partial hospital

Assertive Community Treatment

Intensive home based services

Multi-systemic Therapy

Intensive Case Management 

Out of Home Residential Services

Crisis residential/stabilization

Adult Substance Abuse Residential

Adult Mental Health Residential 

Youth Substance Abuse Residential

Children's Residential Mental Health 

Therapeutic foster care

Acute Intensive Services

Mobile crisis

Peer based crisis services

Urgent care

23 hr. observation bed

Inpatient detoxification

24/7 crisis hotline
111

MHBG Block Grant Expenditures by Service

MHBG Table 3 

State Identifier:

Report Period- From: To:

Service

Unduplicated 

Individuals

Unit

Type

Unit

Quantity

MHBG 

Expenditures

Other (please list)
112

MHBG Table 4 Set-Aside for Children’s Mental Health Services

States and Jurisdictions are required not to spend less than the amount expended in FY 2008. 

Statewide Expenditures for Children’s Mental Health Services

MHBG Table 4:

State Identifier:

Report Period: From: To:

Actual SFY 2008 Actual SFY 2014
MHBG Table 5 (URS Table 8) Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities

This table is used to describe the use of MHBG funds for non-direct service activities that are sponsored, or conducted, by the State Mental Health 

Authority. 

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 5 Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities

State Identifier:

Report Period- From: To:

Service Expenditures

MHA Technical Assistance Activities

MHA Planning Council Activities

MHA Administration

MHA Data Collection/Reporting

MHA Activities Other Than Those Above

Total Non-Direct Services

Comments on Data:
114

MHBG Table 6 (URS Table 10) Statewide Entity Inventory

Statewide Entity Inventory

MHBG Table 6 

State Identifier:

Report Period- From: To:

Source of Funds

SA Block Grant MH Block Grant

A B B D E F G H

Entity

Number 

I-SATS 

ID (for 

SABG)

Area 

Served 

(Statewide 

or SubState 

Planning 

Area)

Provider/Program 

Name

Street 

Address

City State Zip Total 

Block 

Grant 

Funds

Prevention 

(other than 

primary 

prevention) 

and 

Treatment 

Services 

Pregnant 

Women and 

Women 

with 

Dependent 

Children

Primary 

Prevention

Early 

Intervention 

Services for 

HIV

Adults 

with 

serious 

mental 

illness

Children with a 

serious emotional 

disturbance

Non-Direct 

Service 

Activities

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $
MHBG Table 7 Maintenance of Effort for State Expenditures on Mental Health Services

Maintenance of Effort for State Expenditures on Mental Health Services

MHBG Table 7: 

State Identifier:

Report Year: 

Total Expenditures for State _____

Period

A

Expenditures

B

B1 (2012) + B2 (2013)

2

C

SFY 2012

(1)

SFY 2013

(2)

SFY 2014

(3)

Are the expenditure amounts reported in Column B “actual” expenditures for the fiscal years 

involved?

Yes No

SFY 2012

SFY 2013

SFY 2014

If any estimated expenditures are provided, please indicate when “actual” expenditure data will be 

submitted to SAMHSA: ___/___/_____

mm/dd/yyyy
116

D. Populations and Services Report

States and Jurisdictions are requested to provide information regarding individuals that are served by 

the state mental health authority using MHBG Tables 8 through 14. 

MHBG Table 8A and 8b Profile of Clients by Type of Funding Support MHBG Tables 8A and 8B 

provide the number of female and male clients by race and by ethnicity that have: Medicaid Only, 

Non-Medicaid Sources, Both Medicaid and Non-Medicaid, and Status Not Available.

MHBG Table 9 (URS Table 1) Profile of the State Population by Diagnosis MHBG Table 9 

provides the number of Adults with SMI and Children with SED in the reporting year and in three 

years forward.

MHBG Table 10 (URS Table 12) State Mental Health Agency Profile MHBG Table 10 provides the 

Populations covered in State hospitals and Community program in age categories; 0-3, 4-17 and 18 

and above. 

MHBG Tables 11A and 11B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by 

Age, Gender and Race/Ethnicity MHBG Tables 11A and 11B provide an aggregate profile of 

unduplicated persons in the reporting year. The reporting year should be the latest state fiscal year for 

which data are available. This profile is based on a client receiving services in programs provided or 

funded by the state mental health agency. The client profile takes into account all institutional and 

community services for all such programs. States and Jurisdictions are to provide this information on 

all programs by age, gender, race/ethnicity. 

MHBG Table 12 (URS Table 3) Profile of Persons Served In the Community Mental Health Settings, 

State Psychiatric Hospitals and Other Settings MHBG Table 12 provides an aggregate profile of 

unduplicated persons in the reporting year for services funded through the MHBG. The reporting 

year should be the latest state fiscal year for which data are available. This profile is based on a client 

receiving services in programs provided or funded by the MHBG. The client profile takes into 

account all institutional and community services for all such programs. States and Jurisdictions are 

to provide this information on all programs by age, gender, race, and ethnicity. 

MHBG Tables 13A,13 B and 13C (URS Tables 14A and 14B) Profile of Persons with SMI/SED 

Served By Age, Gender and Race/Ethnicity MHBG Tables 13A, 13B and 13C request counts for 

persons with SMI or SED using the definitions provided by the CMHS. MHBG Tables 13A, 13B and 

13C included individuals receiving services in programs provided or funded by the state mental 

health agency. These tables count only clients who meet the CMHS definition of SMI or SED. States 

and Jurisdictions should report using the Federal Definitions of SMI and SED if they can report 

them, if not, please report using the state’s definitions of SMI and SED and provide information in 

these tables describing your state’s definition.

MHBG Table 14 (URS Table 6) Profile of Client Turnover MHBG Table 14 requests information 

regarding the profile of client turnover in various out-of-home settings (e.g. state hospitals, inpatient 
117

psychiatric hospitals, residential treatment centers). Information collected by this table requests 

admissions, discharges, and length of stay.
 

MHBG Table 8A. Profile of Clients by Type of Funding Support (URS 

Table 5A)

This table provides a summary of clients by Medicaid coverage. Since the focus of the reporting is on clients of the public mental health service delivery system, this table 

focuses on the clientele serviced by public programs that are funded or operated by the State Mental Health Authority. Persons are to be counted in the Medicaid row if they 

received a service reimbursable through Medicaid.

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

MHBG Table 8A

Report Period- From: To:

State Identifier:

Total American Indian or Alaska Native Asian Black or African American

Female Male

Not 

Available Total Female Male Not Available Female Male Not Available Female Male Not Available

Medicaid (only Medicaid)

Non-Medicaid Sources (only)

People Served by Both Medicaid and 

Non-Medicaid Sources

Medicaid Status Not Available

Total Served

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their treatment, and 

(4) Medicaid Status Not Available.

If a state is unable to unduplicate between people whose care is paid for by Medicaid only or Medicaid and other funds, then all data should be reported into the 'People Served 

by Both Medicaid and Non-Medicaid Sources' and the 'People Served by Both includes people with any Medicaid' check box should be checked.
(continued on next page)

MHBG Table

8A (Con’t)

Report 

Period- From: 

To: 

State 

Identifier:

Native Hawaiian or Other 

Pacific Islander

White Hispanic * use only if data for 

MHBG Table 3b are not 

available.

More Than One Race 

Reported

Race Not Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Medicaid 

(only 

Medicaid)

NonMedicaid 

Sources 

(only)

People 

Served by 

Both 

Medicaid and 

NonMedicaid 

Sources

Medicaid 

Status Not 

Available

Total Served
120

MHBG Table 8B. (URS Table 5B) Profile of Clients by Type of Funding Support

Of the total persons covered by Medicaid, please indicate the gender and number of persons who are Hispanic/Latino or not Hispanic/Latino. Total persons 

covered by Medicaid would be the total indicated in MHBG Table 8A. 

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

MHBG Table 8B.

Report Period- From To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino 

Origin Unknown Total

Female Male

Not 

Available Female

Ma

l

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Medicaid Only

Non-Medicaid Only

People Served by Both Medicaid and NonMedicaid Sources

Medicaid Status Unknown

Total Served

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their 

treatment, and (4) Medicaid Status Unknown.
MHBG Table 9 (URS Table 1). Profile of the State 

Population by Diagnosis

This table summarizes the estimates of adults residing within the State with serious mental illness (SMI) and 

children residing within the state with serious emotional disturbances (SED). The table calls for estimates for 

two time periods, one for the report year and one for three years into the future. CMHS will provide this data to 

States based on the standardized methodology developed and published in the Federal Register and the 

State level estimates for both adults with SMI and children with SED.

MHBG Table 9

Report Year:

State Identifier:

Current Report Year Three Years Forward

Adults with Serious Mental Illness (SMI)

Children with Serious Emotional Disturbances (SED)

Note: This Table will be completed for the States by CMHS.
122

MHBG Table 10 (URS Table 12): State Mental Health Agency Profile

The purpose of this profile is to obtain information that provides a context for the data provided in the tables. This profile covers the 

populations served, services for which the state mental health agency is responsible, data reporting capacities, especially related to 

duplication of numbers served as well as certain summary administrative information.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 10

Report Year:

State Identifier:

Populations Served

1 Which of the following populations receive services operated or funded by the state mental health agency? Please 

indicate if they are included in the data provided in the tables. (Check all that apply.)

Populations Covered Included in Data

State Hospitals Community Programs State Hospitals

Community 

Programs

1. Aged 0 to 3

2. Aged 4 to 17

3. Adults Aged 18 and over

4. Forensics

Comments on Data:

2 Do all of the adults and children served through the state mental health agency meet the Federal definitions of serious 

mental illness and serious emotional disturbances?

2.a. If no, please indicate the percentage of persons served for the reporting period who met the federal definitions of serious mental 

illness and serious emotional disturbance?

2.a.1 Percent of adults meeting Federal definition of SMI:

2.a.2 Percentage of children/adolescents meeting Federal definition of SED 

3 Co-Occurring Mental Health and Substance Abuse:

3.a. What percentage of persons served by the SMHA for the reporting period have a dual diagnosis of mental illness and substance

abuse?
123

3.a.1 

Percentage of adults served by the SMHA who also have a diagnosis of substance abuse problem:

3.a.2. Percentage of children/adolescents served by the SMHA who also have a diagnosis of substance abuse 

problem:

3.b. What percentage of persons served for the reporting period who met the Federal definitions of adults with SMI and 

children/adolescents with SED have a dual diagnosis of mental illness and substance abuse.

3.b.1 

Percentage of adults meeting Federal definition of SMI who also have a diagnosis of substance abuse problem:

3.b.2. Percentage of children/adolescents meeting the Federal definition of SED who also have a diagnosis of 

substance abuse problem:

3b.3 Please describe how you calculate 

and count the number of persons with 

co-occurring disorders

4 State Mental Health Agency Responsibilities

a. Medicaid: Does the State Mental Health Agency have any of the following responsibilities for mental health services provided 

through Medicaid? (Check All that Apply)

1. State Medicaid Operating Agency

2. Setting Standards

3. Quality Improvement/Program Compliance

4. Resolving Consumer Complaints

5. Licensing

6. Sanctions

7. Other

Are Data for 

these programs 

reported on URS 

b. Managed Care (Mental Health Managed Care Tables?

4.b.1

Does the State have a Medicaid Managed Care initiative?

4.b.2 Does the State Mental Health Agency have any responsibilities for mental health services 

provided through Medicaid Managed Care?

If yes, please check the responsibilities the SMHA has:

4.b.3 Direct contractual responsibility and oversight of the MCOs or BHOs

4.b.4 Setting Standards for mental health services

4.b.5 Coordination with state health and Medicaid agencies

4.b.6 Resolving mental health consumer complaints

4.b.7 Input in contract development

4.b.8 Performance monitoring

4.b.9 Other

5

Data Reporting: Please describe the extent to which your information systems allows the generation of unduplicated 

client counts between different parts of your mental health system. Please respond in particular for Table MHBG 11a and 

MHBG 11b, which require unduplicated counts of clients served across your entire mental health system.
124

Are the data reporting in the 

tables?

5.a. Unduplicated :counted once even if they were served in both State hospitals and community 

programs and if they were served in community mental health agencies responsible for different 

geographic or programmatic areas.

5.b.

Duplicated: across state hospital and community programs

5.c. Duplicated: within community programs

5.d. Duplicated: Between Child and Adult Agencies

5.e. Plans for Unduplication: If you are not currently able to provide unduplicated client counts across all parts of 

your mental health system, please describe your plans to get unduplicated client counts by the end of your Data 

Infrastructure Grant.

6 Summary Administrative Data

6.a. Report Year

6.b. State Identifier

Summary Information on Data Submitted by SMHA:

6.c. Year being reported: From: to

6.d. Person Responsible for Submission

6.e. Contact Phone Number:

6.f. Contact Address

6.g. E-mail:
MHBG Table 11A (URS Table 2A). Profile of Persons Served, All Programs by Age, Gender, Race/Ethnicity

This table provides an aggregate profile of persons in the reporting year. The reporting year should be the latest state fiscal year for which data are 

available. This profile is based on a client receiving services in programs provided or funded by the state mental health agency. The client profile takes 

into account all institutional and community services for all such programs. Please provide unduplicated counts if possible.

Please report the data under the categories listed - "Total" are calculated automatically. 

MHBG Table

11A.

Report Year:

State Identifier:

Total American Indian or Alaska 

Native

Asian Black or African American

Female Male Not 

Availab

le

Total Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

0-17 years

18-24 years

25-44 years

45-64 years

65+ years

Total

Pregnant Women

Are these numbers unduplicated?

Comments on Data (for Age):

Comments on Data (for 

Gender):

Comments on Data (for Race/Ethnicity):

Comments on Data (Overall):

(continued on next page)
126

MHBG Table

11A.

Report Year:

State Identifier:

Native Hawaiian or Other 

Pacific Islander

White Hispanic * use only if data for 

MHBG Table 11b are not 

available.

More Than One Race Reported Race Not 

Available

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

0-17 years

18-24 years

25-44 years

45-64 years

65+ years

Total

Pregnant 

Women
127

MHBG Table 11B (URS Table 2B). Profile of Persons Served, All Programs by Age, Gender and 

Race/Ethnicity

Of the total persons served, please indicate the age, gender and the number of persons who are Hispanic/Latino or 

not Hispanic/Latino. Total persons served would be the total as indicated in MHBG Table 11A.

Please report the data under the categories listed - "Total" are calculated automatically. 

MHBG Table 11B.

Report Year:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

0-17 years

18-24 years

25-44 years

45-64 years

65+ years

Total

Pregnant Women

Comments on Data 

(for Age):

Comments on Data 

(for Gender):

Comments on Data 

(for Ethnicity):

Comments on Data 

(Overall):
128

MHBG Table 12 (URS Table 3). Profile of Persons served in tCommunity Mental Health Settings, State Psychiatric Hospitals and 

OtherSettings

This table provides a profile for the clients that received public funded mental health services in community mental health 

settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

MHBG Table

12

Report Year:

State 

Identifier:

MHBG Table

12

Service Setting

Age 0-17 Age 18-20 Age 21-64 Age 65+

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available

Community 

Mental Health 

Programs

State 

Psychiatric 

Hospitals

Other 

Psychiatric 

Inpatient

Residential 

Treatment 

Centers

(continued on next page)
129

MHBG Table 12 (cont.) Profile of Persons served in Community Mental Health Settings, State Psychiatric Hospitals and Other Settings

Table 12

Report Year:

State Identifier:

Table 12

Service Setting

Age Not Available Total

Female Male Not Available Female Male Not Available Total

Community Mental Health Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same 

year and thus would be reported in counts for both rows.

Instructions:

1 States that have county psychiatric hospitals that serves as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.

2 If forensic hospitals are part of the state mental health agency system include them.

3 Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row

4 Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other Psychiatric 

Inpatient" row. Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.

5 A person who is served in both community settings and inpatient settings should be included in both rows

6

RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned 

programs of mental health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a 

psychiatrist, psychologist, social worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified 

by DSM-IV codes-other than the codes for mental retardation, developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with 

a mental illness).”
130

Table 13A Profile of Persons with SMI/SED Served by Age, Gender and Race/Ethnicity

This table provides a profile for the clients that received public funded mental health services in community mental health 

settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table

13A

Report Year:

State 

Identifier:

MHBG Table

13A

Service Setting

Age 0-17 Age 18-20 Age 21-64

Female Male Not Available Female Male Not Available Female Male Not Available

Community 

Mental Health 

Programs

State 

Psychiatric 

Hospitals

Other 

Psychiatric 

Inpatient

Residential 

Treatment 

Centers

(continued on next page)
131

MHBG Table 13A (cont.) Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings

MHBG Table 13A

Report Year:

State Identifier:

MHBG Table 13A

Service Setting

Age 65+ Age Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Community Mental Health 

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same year and thus would be 

reported in counts for both rows.

Instructions:

1 States that have county psychiatric hospitals that serve as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.

2 If forensic hospitals are part of the state mental health agency system include them.

3 Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row

4 Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other Psychiatric Inpatient" row. 

Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.

5 A person who is served in both community settings and inpatient settings should be included in both rows

6

RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned programs of mental 

health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a psychiatrist, psychologist, social 

worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified by DSM-IV codes-other than the codes for 

mental retardation, developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with a mental illness).”
132

MHBG Table 13B (URS Table 14A). Profile of Persons with SMI/SED served by Age, 

Gender and Race/Ethnicity

This is a developmental table similar to MHBG Tables 11a and 11b (URS Table 2A. and 2B). This table requests counts for persons with SMI or SED using the 

definitions provided by the CMHS. MHBG Table 11A and 11B (URS Table 2A. and 2B). included all clients served by publicly operated or funded programs. This 

table counts only clients who meet the CMHS definition of SMI or SED. For many states, this table may be the same as MHBG Tables 11 A and 11B (URS Table 

2A. and 2B). For 2013, states should report using the Federal Definitions of SMI and SED if they can report them, if not, please report using your state’s definitions 

of SMI and SED and provide information below describing your state’s definition.

Please report the data under the categories listed - "Total" are calculated automatically. 

MHBG Table

13B

Report Year:

State 

Identifier:

Total American Indian or 

Alaska Native

Asian Black or African American Native Hawaiian or Other 

Pacific Islander

Female Male Not 

Available

Total Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

0-12 Years

13-17 years

18-20 years

21-64 years

65-74 years

75+ years

Not Available

Total

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (for Race/Ethnicity):

Comments on Data (Overall):

(continued on next page)
133

(

MHBG Table

13B.

Report Year:

State 

Identifier:

White Hispanic *use only if data 

for MHBG Table 13c are 

not available

More Than One Race 

Reported

Race Not Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not Available

0-12 Years

13-17 years

18-20 years

21-64 years

65-74 years

75+ years

Not Available

Total

1. State Definitions Match the Federal Definitions:

Yes No Adults with SMI, if No describe or attach state definition: 

Yes No Diagnoses included in state SMI definition:

Yes No Children with SED, if No describe or attach state definition:

Yes No Diagnoses included in State SED definition:
134

MHBG Table 13C (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender 

and Ethnicity

Of the total persons served, please indicate the age, gender and the number of persons who meet the Federal definition of SMI and SED and who are Hispanic/Latino or not 

Hispanic/Latino. The total persons served who meet the Federal definition of SMI or SED should be the total as indicated in MHBG Table 13b.

Please report the data under the categories listed - "Total" are calculated automatically. 

MHBG Table 13C

Report Year:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

0 - 12 Years

13 - 17 years

18 - 20 years

21-64 years

65-74 years

75+ years

Not Available

Total

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (for 

Race/Ethnicity):

Comments on Data (Overall):
135

MHBG Table 14 (URS Table 6): Profile of Client Turnover

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 14.

Report Year:

State Identifier:

Profile of Service Utilization

Total Served at 

Beginning of 

Year 

(unduplicated)

Admissions 

During the 

year 

(duplicated)

Discharges 

During the 

year 

(duplicated)

Length of Stay (in 

Days): Discharged 

Patients

For Clients in 

Facility for Less 

Than 1 Year: 

Average Length of 

Stay (in Days): 

Residents at end of 

year

For Clients in Facility More 

Than 1 Year: Average 

Length of Stay (in Days): 

Residents at end of year

Average 

(Mean) Median

Average 

(Mean) Median

Average 

(Mean) Median

State Hospitals

 Children (0 to 17 years)

 Adults (18 yrs and over)

 Age Not Available

Other Psychiatric Inpatient

 Children (0 to 17 years)

 Adults (18 yrs and over)

 Age Not Available

Residential Tx Centers

 Children (0 to 17 years)

 Adults (18 yrs and over)

 Age Not Available

Community Programs

 Children (0 to 17 years)

 Adults (18 yrs and over)

 Age Not Available

Comments on Data (State Hospital):

Comments on Data (Other Inpatient):

Comments on Data (Residential 

Treatment):

Comments on Data (Community 

Programs):

Comments on Data (Overall):
E. Performance Data and Outcomes

MHBG Table 15 (URS Table 17) Profile of Adults with Serious Mental Illnesses Receiving Specific 

Services during the Year MHBG Table 15 provides the number of unduplicated Adults with SMI 

receiving family psycho education, integrated treatment for co-occurring disorders, illness selfmanagement and medication management.

MHBG Table 16A (URS Table 4) Profile of Adult Clients by Employment Status MHBG Table 16A 

describes the status of adults clients served in the report year by the public mental health system in 

terms of employment status. The focus is on employment for the working age population, 

recognizing, however, that there are clients who are disabled, retired or who homemakers, caregivers, are etc and not a part of the workforce. These persons should be reported in the “Not in Labor 

Force” category. This category has two subcategories: retired and other. (The totals of these two 

categories should equal the number in the row for “Not in Labor Force”). Unemployed refers to 

persons who are looking for work but have not found employment. Data should be reported for 

clients in non-institutional settings at time of discharge or last evaluation.

MHBG Table 16B (URS Table 4A) Profile of Adult Clients by Employment Status, by Primary 

Diagnosis Reported MHBG Table 16B request information on the status of adult clients served in 

the report year by the public mental health system in terms of employment status by primary 

diagnosis reported.

MHBG Table 17 (URS Table 15) Living Situation Profile MHBG Table 17 requests information 

regarding the number of Individuals in Each Living Situation as collected by the most recent 

assessment in the reporting period. Specifically, information is collected on the individual’s last 

known living situation. Living situations include, but are not limited to: private residence, foster 

care, residential care, jail/correctional facility, homeless shelter and other.

MHBG Table 18 (URS Table 19B) Profile of Change in School Attendance MHBG Table 18 

measures the change in days attended over time. Information requested includes information on 

suspensions, expelled, and changes in the school attendance.

MHBG Table 19 (URS Table 9) Social Connectedness and Improved Functioning MHBG Table 19 

requests states and jurisdictions to provide information for youth and adults regarding Social 

Connectedness. In addition, States are requested to provide information on functional domains that 

provide a general sense of an individual’s ability to develop and maintain relationships, cope with 

challenges and a sense of community belonging.

MHBG Table 20A (URS Table 11) Summary Profile of Client Evaluation of Care MHBG Table

20A requests information that evaluates the “experience” of care for individuals that participate in 

the public mental health system. Specifically, the evaluation focuses on several areas including: 

access, quality and the appropriateness of services, participation in treatment planning and general 

satisfaction with services. Please provide unduplicated counts, if possible. This table provides an 

aggregate profile of persons served in the reporting year. The reporting year should be the latest state 
137

fiscal year for which data are available. This profile is based on a client's last known Living 

Situation.

MHBG Table 20B (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: 

Race/Ethnicity

MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice Involvement

MHBG Table 21 requests information to measure the change in Arrests over time.

MHBG Table 22 (URS Table 16) Profile of Adults with Serious Mental Illnesses and Children with

Serious Emotional Disturbances Receiving Specific Services MHBG Table 22 requests information 

regarding the number and demographics of individuals that are receiving specific evidenced-based 

services. In addition, the table requests information on if and how States and Jurisdictions monitor 

the fidelity for the evidenced based services.

MHBG Table 23A (URS Table 20A) Profile of Non-Forensic (Voluntary and Civil-Involuntary) 

Patients Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge 

MHBG Table 23A provides the total number of discharges within the year, the number of 

readmissions within 30-days and 180-days and the percent readmitted by age, gender, race, and 

ethnicity.

MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to Any State 

Psychiatric Inpatient Hospital within 30/180 Days of Discharge MHBG Table 23B provides the 

total number of discharges within the year, the number of readmissions within 30-days and 180-days 

and the percent readmitted by age, gender, race, and ethnicity.

MHBG Table 24 (URS Table 21) Profile of Non-Forensic (Voluntary and Civil-Involuntary 

Patients) Readmission to Any Psychiatric Inpatient Care Unit (State Operated or Other Psychiatric 

Inpatient Unit) within 30/180 Days of Discharge MHBG Table 24 provides the total number of 

discharges from inpatient care units w/I the year, the number of readmissions w/I 30-days and 180-

days and the percent readmitted by age, gender, race, and ethnicity.
138

MHBG Table 15 (URS Table 17): Profile of Adults with Serious Mental Illnesses Receiving Specific Services 

During The Year:

MHBG Table 15

Report Year:

State Identifier:

ADULTS WITH SERIOUS MENTAL 

ILLNESS

Receiving Family 

Psychoeducation

Receiving Integrated 

Treatment for Co-occurring 

Disorders (MH/SA)

Receiving 

Illness Self 

Management

Receiving Medication 

Management

Age

18-20

21-64

65-74

75+

Not Available

TOTAL

Gender

Female

Male

Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Unknown

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Hispanic origin not available

Do You monitor fidelity Yes No Yes No Yes No Yes No

for this service?

IF YES,

What fidelity measure do you use?

Who measures fidelity?

How often is fidelity measured?

 Yes No Yes No Yes No Yes No

Is the SAMHSA EBP Toolkit used to guide EBP Implementation?

Have staff been specifically trained to implement the EBP?
139

* Hispanic is part of the total served.

Comments on Data (overall):

Comments on Data (Family Psychoeducation):

Comments on Data (Integrated Treatment for Co-occurring Disorders):

Comments on Data (Illness Self Management):

Comments on Data (Medication Management):

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

 
MHBG Table 16A (URS Table 4) Profile of Adult Clients by 

Employment Status

This table describes the status of adults clients served in the report year by the public mental health system in terms of employment status. The focus is on employment for the working age 

population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, care-givers, etc and not a part of the workforce. These persons should be reported in 

the “Not in Labor Force” category. This category has two subcategories: retired and other. (The totals of these two categories should equal the number in the row for “Not in Labor Force”). 

Unemployed refers to persons who are looking for work but have not found employment. Data should be reported for clients in non-institutional settings at time of discharge or last 

evaluation.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 16 A

Report Year:

State Identifier:

18-20 21-64 65+ Age Not Available Total

Adults Served Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Employed: 

Competitively 

Employed Full or 

Part Time (includes 

Supported 

Employment)

Unemployed

Not In Labor Force: 

Retired, Sheltered 

Employment, 

Sheltered 

Workshops, Other 

(homemaker, 

student, volunteer, 

disabled, etc.)

Not Available

Total

How Often Does your State Measure Employment Status?

What populations are included:

Comments on Data (for 

Age):

Comments on Data (for 

Gender):

Comments on Data 

(Overall):
MHBG Table 16B (URS Table 4A) Optional Profile of Adult Clients by Employment Status: by Primary 

Diagnosis Reported

The workgroup exploring employment found that the primary diagnosis of consumers results in major differences in employment status. The workgroup has 

recommended that we explore the ability of states to report employment by primary diagnosis and the impact of diagnosis on employment. The workgroup 

recommended 5 diagnostic clusters for reporting.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR 

CELLS!

MHBG Table 10020

Report Year:

State Identifier:

Clients

Primary Diagnosis

Employed: 

Competitively Employed 

Full or Part Time 

(includes Supported 

Employment) Unemployed

Not In Labor Force: 

Retired, Sheltered 

Employment, Sheltered 

Workshops, Other 

(homemaker, student, 

volunteer, disabled, 

etc.)

Employment Status 

Not Available Total

Schizophrenia & Related Disorders 

(295)

Bipolar and Mood Disorders (296, 300.4, 

301.11, 301.13, 311)

Other Psychoses (297, 298)

All Other Diagnoses

No Dx and Deferred DX (799.9, V71.09)

Diagnosis Total

Comments on Data (for Diagnosis):
MHBG Table 17 (URS Table 15). 

Living Situation Profile: 

Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period 

All Mental Health Programs by Age, Gender, and Race/Ethnicity

Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal 

year for which data are available. This profile is based on a client's last known Living Situation. 

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 18

Report Year:

State Identifier:

Private 

Residence

Foster 

Home

Residential 

Care

Crisis 

Residence

Children's 

Residential 

Treatment

Institutional 

Setting

Jail/ 

Correctional 

Facility

Homeless/ 

Shelter Other NA Total

0-17

18-64

65 +

Not Available

TOTAL

Female

Male

Not Available

TOTAL

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White/Caucasian

Hispanic *

More than One Race Reported

Race/Ethnicity Not Available

TOTAL

(continued on next page)
MHBG Table 17 (cont.) Living 

Situation Profile: 

Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period 

All Mental Health Programs by Age, Gender, and Race/Ethnicity

Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal 

year for which data are available. This profile is based on a client's last known Living Situation. 

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Please report the data under the Living Situation categories listed - "Total" are calculated automatically. 

MHBG Table 17

Report Year:

State Identifier:

Private 

Residence

Foster 

Home

Residential 

Care

Crisis 

Residence

Children's 

Residential 

Treatment

Institutional 

Setting

Jail/ 

Correctional 

Facility

Homeless/ 

Shelter Other NA Total

Hispanic or Latino Origin

Non Hispanic or Latino Origin

Hispanic or Latino Origin Not Available

TOTAL

Comments on Data:

How Often Does your State Measure Living 

Situation?

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available
Table 18 (URS Table 19b) Profile of Change in School Attendance

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

1. This is a developmental measure. To assist in the development process, we are asking states to report information on the school attendance outcomes of mental health consumers with their December 2007 MHBG submission.

2. The SAMHSA National Outcome Measure for School Attendance measures the change in days attended over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3

Consumer Self-Report items on School Attendance, you may report them here.

3. If your SMHA has data on School Attendance from alternatives sources, you may also report that here. If you only have data for School attendance for consumers in this year, please report that in the T2 columns. If you can calculate the change in Attendance from T1 to T2, please use all these columns.

4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.

5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether treatment data are collected).

Table 19b. Profile of Change in School Attendance

State: Time period in which services were received:

For Consumers in Service for at least 12 months

T1 T2 T1 to T2 Change Impact of Services

"T1" Prior 12 months

(more than 1 year ago)

"T2" Most Recent 12 months

(this year) If Suspended at T1 (Prior 12 Months) If Not Suspended at T1 (Prior 12 Months) Over the last 12 months, the number of days my child was in school have

# Suspended 

or Expelled

# Not 

Suspended or 

Expelled

No

Response

# Suspended 

or Expelled

# Not 

Suspended or 

Expelled

No

Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension 

or Expulsion 

at T2 No Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension 

or Expulsion 

at T2

No

Response

# Greater

(Improved)

# Stayed 

the Same

# Fewer days

(gotten 

worse)

# Not

Applicable

No 

response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Gender

Male 0

Female 0

Gender NA 0

Age

Under 18 0

For Consumers Who Began Mental Health Services during the past 12 month

T1 T2 T1 to T2 Change Impact of Services

"T1" 12 months prior to beginning 

services

"T2" Since Beginning Services

(this year) If Suspended at T1 (Prior 12 Months)

If Not Suspended at T1 

(Prior 12 Months)

Since starting to receive MH Services, the number of days my child was in 

school have

# Suspended 

or Expelled

# Not 

Suspended or 

Expelled

No

Response

# Suspended 

or Expelled

# Not 

Suspended or 

Expelled

No

Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension 

or Expulsion 

at T2 No Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension 

or Expulsion 

at T2

No

Response

# Greater

(Improved)

# Stayed 

the Same

# Fewer days

(gotten 

worse)

# Not

Applicable

No 

response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Gender

Male 0

Female 0

Gender NA 0

Age

Under 18 0

See Page 2 for additional Questions about the source of this data.

Source of School Attendance Information 1) Consumer survey (recommended items) 2) Other Survey: Please send us items 3) Mental health MIS

4) State Education Department 5) Local Schools/Education Agencies 6) Other (specify)

Measure of School Attendance 1) School Attendance 2) Other: (Specify)

Mental health programs include: 1) Children with SED only 2) Other Children (specify) 3) Both.

Region for which data are reported: 1) The whole state 2) Less than the whole state (please describe)

What is the Total Number of Persons Surveyed or for whom School Attendance Data Are Reported

Child/Adolescents

1. If data is from a survey, What is the total Number of people from which the sample was drawn?

2. What was your sample size? (How many individuals were selected for the sample)?

3. How many survey Contacts were made? (surveys to valid phone numbers or addresses)

4. How many surveys were completed? (survey forms returned or calls completed) If data source was not 

a Survey, How many persons were data available for?

5. What was your response rate? (number of Completed surveys divided by number of Contacts):
MHBG Table 19 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS 

AND/OR CELLS!

MHBG Table 19: NOMS Social Connectedness & Functioning

Report Year (Year Survey was Conducted):

State Identifier:

Adult Consumer Survey Results: Number of Positive 

Responses

Responses Percent Positive 

(calculated)

1. Social Connectedness

2. Functioning

Child/Adolescent Consumer Survey Results: Number of Positive 

Responses

Responses Percent Positive 

(calculated)

3. Social Connectedness

4. Functioning

Comments on Data:

Adult Social Connectedness and Functioning Measures

1. Did you use the recommended new Social Connectedness Questions? Yes No Measure used

2: Did you use the recommended new Functioning Domain Questions? Yes No Measure used

3. Did you collect these as part of your MHSIP Adult Consumer Survey? Yes No 

If No, what source did you use?

Child/Family Social Connectedness and Functioning Measures

4: Did you use the recommended new Social Connectedness Questions? Yes No Measure used

5: Did you use the recommended new Functioning Domain Questions? Yes No Measure used

6. Did you collect these as part of your YSS-F Survey? Yes No 

If No, what source did you use?
146

Recommended Scoring Rules

Please use the same rules for reporting Social connectedness and Functioning Domain scores as for calculating

other Consumer Survey Domain scores for Table MHBG Table 

20a: E.g.:

1. Recode ratings of “not applicable” as missing values.

2. Exclude respondents with more than 1/3rd of the items in that domain missing.

3. Calculate the mean of the items for each respondent.

4. FOR ADULTS: calculate the percent of scores less than 2.5. (percent agree and strongly agree).

5. FOR YSS-F: calculate the percent of scores greater than 3.5. (percent agree and strongly agree).
Items to Score in the Functioning Domain:

Adult MHSIP Functioning Domain:

1 I do things that are more meaningful to me. 

2 I am better able to take care of my needs. 

3 I am better able to handle things when they go wrong. 

4 I am better able to do things that I want to do. 

5 My Symptoms are not bothering me as much (this question already is part of the MHSIP Adult Survey)

YSS-F Functioning Domain Items:

1 My child is better able to do things he or she wants to do. 

2 My child is better at handling daily life. (existing YSS-F Survey item)

3 My child gets along better with family members. (existing YSS-F Survey item)

4 My child gets along better with friends and other people. (existing YSS-F Survey item)

5 My child is doing better in school and/or work. (existing YSS-F Survey item)

6 My child is better able to cope when things go wrong. (existing YSS-F Survey item)

Items to Score in the Social Connectedness Domain:

Adult MHSIP Social Connectedness Domain:

1 I am happy with the friendships I have. 

2 I have people with whom I can do enjoyable things.

3 I feel I belong in my community. 

4 In a crisis, I would have the support I need from family or friends. 

YSS-F Social Connectedness Domain Items:

1 I know people who will listen and understand me when I need to talk

2 I have people that I am comfortable talking with about my child's problems.

3 In a crisis, I would have the support I need from family or friends.

4 I have people with whom I can do enjoyable things
148

MHBG Table 20A (URS Table 11): Summary Profile of Client 

Evaluation of Care

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR 

CELLS!

MHBG Table 20A

Report Year (Year Survey was Conducted):

State Identifier:

Adult Consumer Survey Results: Number of 

Positive 

Responses

Responses Confidence Interval*

1. Reporting Positively About Access.

2. Reporting Positively About Quality and Appropriateness for Adults

3. Reporting Positively About Outcomes.

4. Adults Reporting on Participation In Treatment Planning.

5. Adults Positively about General Satisfaction with Services.

Child/Adolescent Consumer Survey Results: Number of 

Positive 

Responses

Responses Confidence Interval*

1. Reporting Positively About Access.

2. Reporting Positively about General Satisfaction for Children.

3. Reporting Positively about Outcomes for Children.

4. Family Members Reporting on Participation In Treatment Planning for their Children

5. Family Members Reporting High Cultural Sensitivity of Staff.

Please enter the number of persons responding positively to the questions and the number of total responses

within each group. Percent positive will be calculated from these data.

* Please report Confidence Intervals at the 95% level. See directions below regarding the calculation of confidence intervals.

Comments on Data:

Adult Consumer Surveys

1. Was the Official 28 Item MHSIP Adult Outpatient Consumer Survey Used?

1.a. If no, which version:

1. Original 40 Item Version

2. 21-Item Version 

3. State Variation of MHSIP

4. Other Consumer Survey

1.b. If other, please attach instrument used.

1.c. Did you use any translations of the MHSIP into another language?

2. Other Language:

Adult Survey Approach:

2. Populations covered in survey? (Note all surveys should cover all regions of state)
149

2.a. If a sample was used, what sample methodology was used?

4. Other Sample:

Adult Consumer Surveys (Continued)

2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?

3. Please Describe the populations included in your sample: (e.g., all adults, only adults with SMI, etc.)

 3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):

4. Methodology of collecting data? (Check all that apply)

Self-Administered Interview

Phone

Mail

Face-to-face

Web-Based

4.b. Who administered the Survey? (Check all that apply)

 6. Other: describe:

5. Are Responses Anonymous, Confidential and/or Linked to other Patient Databases?

6. Sample Size and Response Rate

6a. How many Surveys were Attempted (sent out or calls initiated)?

6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)

6.c How many surveys were completed? (survey forms returned or calls completed)

6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)

6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count these survey's as "completed" 

for the calculation of response rates?

7. Who Conducted the Survey

7.a. SMHA Conducted or contracted for the Survey (survey done at state level)

7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey

 (survey was done at the local or regional level)

7.c. Other: Describe:

* Report Confidence Intervals at the 95% confidence level
150

Note: The confidence interval is the plus-or-minus figure usually reported in newspaper or television opinion poll results. For example, if you 

use a confidence interval of 4 and 47% percent of your sample picks an answer you can be "sure" that if you had asked the question of the 

entire relevant population between 43% (47-4) and 51% (47+4) would have picked that answer.

The confidence level tells you how sure you can be. It is expressed as a percentage and represents how often the true percentage of the 

population who would pick an answer lies within the confidence interval. The 95% confidence level means you can be 95% certain; the 99% 

confidence level means you can be 99% certain. Most researchers use the 95% confidence level.

When you put the confidence level and the confidence interval together, you can say that you are 95% sure that the true percentage of the 

population is between 43% and 51%. (From www.surveysystem.com)

Child/Family Consumer Surveys

1. Was the MHSIP Children/Family Survey (YSS-F) Used?

If No, what survey did you use?

 If no, please attach instrument used.

1.c. Did you use any translations of the Child MHSIP into another language?

2. Other Language:

Child Survey Approach:

2. Populations covered in survey? (Note all surveys should cover all regions of state)

2.a. If a sample was used, what sample methodology was used?

4. Other Sample:

2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?

 2a. If yes to 2, please describe how your survey persons no longer receiving services.

3. Please Describe the populations included in your sample: (e.g., all children, only children with SED, etc.)

 3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):

4. Methodology of collecting data? (Check all that apply)

Self-Administered Interview

Phone

Mail

Face-to-face

Web-based

4.b. Who administered the Survey? (Check all that apply)

6. Other: describe:
151

5. Are Responses Anonymous, Confidential and/or Linked to other Patient Databases?

6. Sample Size and Response Rate

6a. How many Surveys were Attempted (sent out or calls initiated)?

6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)

6.c How many surveys were completed? (survey forms returned or calls completed)

6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)

6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count

 these survey's as "completed" for the calculation of response rates?

7. Who Conducted the Survey

7.a. SMHA Conducted or contracted for the Survey (survey done at state level)

7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey

 (survey was done at the local or regional level)

7.c. Other: Describe:
Table 20b.

Report Year:

State Identifier:

Adult Consumer Survey Results:

*State used the 2 question version for

Hispanic Origin Yes No Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about

Hispanic Origin/Status

Indicators Total

AmericanIndian or

Alaska Native Asian Black or African American

Native Hawaiian or Other

Pacific Islander White

More than One Race

Reported Other/ Not Available Hispanic Origin*

Adult Consumer

Survey Results: # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses

1. Reporting Positively

About Access.

2. Reporting Positively

About Quality and

Appropriateness.

3. Reporting Positively

About Outcomes.

4. Reporting Positively

about Participation in

Treatment Planning

5. Reporting Positively

about General

Satisfaction

6. Social Connectedness

7. Functioning

Child/Adolescent Family Survey Results:

*State used the 2 question version for

Hispanic Origin Yes No Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about

Hispanic Origin/Status

Indicators Total

AmericanIndian or

Alaska Native Asian Black or African American

Native Hawaiian or Other

Pacific Islander White

More than One Race

Reported Other/ Not Available Hispanic Origin*

Child/Adolescent

Family Survey Results:

# Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses

Reporting Positively

About Access.

Reporting Positively

About General

Satisfaction

Reporting Positively

About Outcomes.

Reporting Positively

Participation in Treatment

Planning for their

Children.

Reporting Positively

About Cultural Sensitivity 

of Staff.

6. Social Connectedness

7. Functioning

MHBG Table 20b (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: (Optional Table by Race/Ethnicity.)

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Comments on Data:

Please enter the number of persons responding positively to the questions and the number of total responses within each group. Percent positive will be calculated from these data.
153

MHBG Table 21 (URS Table 19a) Profile of Criminal Justice or Juvenile Justice Involvement:

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

1. This is a developmental measure. To assist in the development process, we are asking states to report information on the arrest histories of mental health consumers with their December 2007 MHBG submission.

2. The SAMHSA National Outcome Measure for Criminal Justice measures the change in Arrests over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If 

your state has used the 3 Consumer self-report items on criminal justice, you may report them here.

3. If your SMHA has data on Arrest records from alternatives sources, you may also report that here. If you only have data for arrests for consumers in this year, please report that in the T2 columns. If you can calculate the change 

in Arrests from T1 to T2, please use all those columns.

4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.

5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether 

treatment data are collected).

State: Time period in which services were received:

For Consumers in Service for at least 12 months

T1 T2 T1 to T2 Change Assessment of the Impact of Services

"T1" Prior 12 months

(more than 1 year ago)

"T2" Most Recent 12 months

(this year) If Arrested at T1 (Prior 12 Months) If Not Arrested at T1 (Prior 12 Months) Over the last 12 months, my encounters with the police have...

Arrested

Not

Arrested

No

Response

Not No

Arrested Arrested Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# Reduced 

(fewer 

encounters)

# Stayed 

the Same

# 

Increased

# Not

Applicable

No

Response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Children/Youth (under age 18) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

Total Adults (age 18 and over) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

For Consumers Who Began Mental Health Services during the past 12 months

T1 T2 T1 to T2 Change Assessment of the Impact of Services

"T1" 12 months prior to beginning 

services

"T2" Since Beginning Services

(this year) If Arrested at T1 (Prior 12 Months) If Not Arrested at T1 (Prior 12 Months) Since starting to receive MH Services, my encounters with the police have...

Arrested

Not

Arrested

No

Response

Not No

Arrested Arrested Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# Reduced 

(fewer 

encounters)

# Stayed 

the Same

# 

Increased

# Not

Applicable

No

Response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Children/Youth (under age 18) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

Total Adults (age 18 and over) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0
154
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Table 22.

Report Year:

State Identifier:

N 

Receiving 

Supported 

Housing

N Receiving 

Supported 

Employment

N Receiving 

Assertive 

Community 

Treatment

Total 

unduplicated 

N - Adults 

with SMI 

served

N Receiving 

Therapeutic 

Foster Care

N Receiving 

MultiSystemic 

Therapy

N Receiving 

Family 

Functional 

Therapy

Total 

unduplicated 

N - Children 

with SED

Age

 0-12

13-17

18-20

21-64

65-74

75+

Not Available

TOTAL 0 0 0 0 0 0 0 0

Gender

Female

Male

Not Available

Race/Ethnicity

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Not Available

Do You monitor fidelity Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

 for this service?

IF YES,

What fidelity measure do you use?

Who measures fidelity?

How often is fidelity measured?

Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

Is the SAMHSA EBP Toolkit used to 

guide EBP Implementation?

Have staff been specifically trained 

to implement the EBP?

* Hispanic is part of the total served.

Comments on Data (overall):

Comments on Data (Supported 

Housing):

Comments on Data (Supported 

Employment):

Comments on Data (Assertive 

Community Treatment):

Comments on Data (Therapeutic 

Foster Care):

Comments on Data (Multi-Systemic 

Therapy):

Comments on Data (Family 

Functional Therapy):

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

Table 22: Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving 

Specific Services:

Adults with Serious Mental Illness (SMI) Children with Serious Emotional Disturbance (SED)

Yes No
 MHBG Table 23A (URS Table 20A). Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients 

Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge

MHBG Table 23A.

Report Year:

State Identifier:

Total number of 

Discharges in 

Year

Number of Readmissions to 

ANY STATE Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Hispanic/Latino Origin Not Available

Are Forensic Patients Included?

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
157

MHBG Table 23B (URS Table 20B). Profile of Forensic Patients Readmission to Any State Psychiatric 

Inpatient Hospital Within 30/180 Days of Discharge

MHBG Table 23B.

Report Year:

State Identifier:

Total number 

of Discharges 

in Year

Number of Readmissions to 

ANY STATE Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Hispanic/Latino Origin Not Available

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
158

MHBG Table 24 (URS Table 21). Profile of Non-Forensic (Voluntary and Civil-Involuntary Patients) 

Readmission to Any Psychiatric Inpatient Care Unit (State Operated or Other Psychiatric Inpatient Unit) 

Within 30/180 Days of Discharge

MHBG Table 24.

Report Year:

State Identifier:

Total number 

of Discharges 

in Year

Number of Readmissions to ANY 

Psychiatric Inpatient Care Unit 

Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Hispanic/Latino Origin Not Available

1. Does this table include readmission from state psychiatric hospitals?

2. Are Forensic Patients Included? 

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
159

Block Grant Reporting Section 

FY 2014

CFDA 93.959 

(Substance Abuse Prevention and Treatment)

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration
160

Table of Contents 

A. Introduction

B. Annual Update

SABG Table 1 Priority Area and Annual Performance Indicators – Progress Report

C. State Agency Expenditure Reports

SABG Table 2 - State Agency Expenditure Report

SABG Table 3 - SABG Expenditures by Service

SABG Table 4 - SABG State Agency Expenditure Compliance Report

SABG Table 5a - SABG Primary Prevention Expenditures Checklist 

SABG Table 5b - SABG Primary Prevention Expenditures by IOM Category

SABG Table 5c - SABG Primary Prevention Targeted Priorities

SABG Table 6 - SABG Resource Development Expenditure Checklist 

SABG Table 7 - SABG Statewide Entity Inventory

SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse

Prevention and Treatment

SABG Table 8b - Base and Maintenance of Effort for Statewide Non-Federal Expenditures 

for Tuberculosis to Individuals in Substance Use Disorder Treatment, 

SABG Table 8c - Base and Maintenance of Effort for Statewide Non-Federal Expenditures 

for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment

SABG Table 8d - Base and Maintenance of Effort for Expenditures for Services to Pregnant 

Women and Women with Dependent Children

D. Population and Services Reports

SABG Table 9 - Prevention Strategy Report

SABG Table 10 - Treatment Utilization Matrix 

SABG Table 11 - Number of Persons Served (Unduplicated Count) for Alcohol and Other 

Drug Use

SABG Table 12 - SABG HIV Early Intervention Services in Designated States

SABG Table 13 - Charitable Choice

 E. Performance Data and Outcomes

Treatment Performance Measures

SABG Table 14 - Employment/Education Status

SABG Table 15 - Stability of Housing
161

SABG Table 16 - Criminal Justice Involvement

SABG Table 17 -Change in Abstinence–Alcohol Use 

SABG Table 18 - Change in Abstinence – Other Drug Use

SABG Table 19 - Change in Social Support of Recovery 

SABG Table 20 - Retention

Prevention Performance Measures

SABG Table 21 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: 30 

Day Use 

SABG Table 22 - Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure:

Perception Of Risk/Harm of Use

SABG Table 23 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: 

Age of First Use

SABG Table 24 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: 

Perception of Disapproval/Attitudes

SABG Table 25 - Employment/Education; Measure: Perception of Workplace Policy

SABG Table 26 - Employment/Education; Measure: Average Daily School Attendance Rate

SABG Table 27 - Crime and Criminal Justice; Measure: Alcohol-Related Traffic Fatalities

SABG Table 28 - Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests

SABG Table 29 - Social Connectedness; Measure: Family Communications around Drug and 

Alcohol Us

SABG Table 30 - Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or 

Listening to a Prevention Message

SABG Table 31 - Individual-Based Programs and Strategies; Measure: Number of Persons 

Served By Age, Gender, Race, and Ethnicity 

SABG Table 32 - Population-Based Programs and Strategies; Measure: Number of Persons 

Served By Age, Gender, Race, and Ethnicity 

SABG Table 33 - Number of Persons Served by Type of Intervention

SABG Table 34 - Number of Evidence-Based Programs by Types of Intervention. 

SABG Table 35 - Number of Evidence-based Programs and Strategies, and Total SA Block 

Grant Funds Spent on Evidence-Based Programs/ Strategies.

Prevention Attachments A, B and C

SABG Table 36 - (Optional Worksheet) Program/Strategy Detail for Computing the Total 

Number of Evidence-based Programs and Strategies, and for Reporting Total SA Block 

Grant Funds Spent on Substance Abuse Prevention Evidence-Based Programs and Strategies
162

Section A. Introduction

Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. 300x-52(a)) requires the 

Secretary of the Department of Health and Human Services, acting through the Administrator of the 

Substance Abuse and Mental Health Services Administration (SAMHSA), to determine the extent to 

which States and Jurisdictions have implemented the State plan for the preceding fiscal year. The 

purpose of the Annual Report is to provide information to assist the Secretary in making this 

determination. 

States and Jurisdictions are required to prepare and submit an Annual Report that includes 

expenditure summaries for 1) the State fiscal year (SFY) immediately preceding the federal fiscal 

year for which the state is applying for funds, and 2) the obligation and expenditure period of the 

Substance Abuse Prevention and Treatment Block Grant (SABG) award subject to CSAT 

compliance review (Compliance Award), in the format provided in this guidance. The Annual Report 

will address the purposes for which the SABG funds were expended, the recipients of grant funds, 

and the authorized activities funded and services purchased with such funds. Particular attention 

should be given to the progress made toward accomplishing the goals and performance indicators 

identified in the States’ and Jurisdictions’ plans. 

All States and Jurisdictions are required to prepare and submit their respective Annual Reports 

utilizing SAMHSA’s Web Block Grant Application System (BGAS). Annual Reports must be 

received by SAMHSA not later than December 1 in order for a State or Jurisdiction to receive its 

next SABG award. If the due date falls on a weekend or Federal holiday, the report will be due on 

the next business day. The following schedule provides specific due dates for Annual Reports, as 

well as for Applications, Plans, and Synar Reports:

Due Dates for SA and Combined BG Components

FY for which the state

is applying for funds

Application

Due

Plan

Due

Planning Period SABG Report 

Due

Synar Report

Due

2014 SA Only

10/1/2013

Combined

9/3/2013

7/1/13 – 6/30/15 12/2/2013

Compliance 

Year 2011

12/31/2013

2015 4/1/2014 No* NA 12/1/2014

Compliance 

Year 2012

12/31/2014

*States may revise previously submitted plans

States and Jurisdictions are required to prepare and submit an Annual report comprised of the 

following sections:

Section B: Annual Update - In this section, States and Jurisdictions are required to provide a brief 

review of the extent to which their respective plans were implemented, and the progress toward the 

priorities and goals identified in the Block Grant plan covering State fiscal years 2014 and 2015. The 

report should also include a brief review of areas that the State or Jurisdiction identified in that Block 

Grant plan as needing improvement and changes that the State or Jurisdiction proposed to achieve the 

goals established for the priorities. 
163

Section C: State Agency Expenditure Reports - In this section, States and Jurisdictions must provide 

information regarding expenditures for authorized activities and services for substance abuse 

prevention and substance use disorder treatment. The State or Jurisdiction must provide a description 

of SABG expenditures for authorized activities to prevent and treat substance abuse and related 

services for tuberculosis and other communicable diseases, and, if it is a “designated State”, a 

description of SABG expenditures for early intervention services (EIS) for HIV. In addition, the 

State or Jurisdiction must identify the SABG expenditures made available to intermediaries, 

administrative service organizations, and community- and faith-based organizations who received 

amounts from the SABG to provide authorized activities to prevent and treat substance abuse.

Section D: Populations and Services Reports - In this section, States and Jurisdictions must provide 

specific information regarding the number of individuals that were served with SABG funds. In 

addition, States and Jurisdictions should provide specific information regarding the services these 

individuals received. 

Section E: Performance Indicators and Accomplishments - In this section of the report, States and 

Jurisdictions are required to complete the Performance Indicator tables. Performance indicators 

should be reported using the table format provided in this document. The purpose of the 

performance indicator tables is to show progress made over time as measured by SAMHSA’s 

National Outcome Measures (NOMS) for substance abuse prevention, treatment, and recovery.
164

B. Annual Update 

The information States and Jurisdictions entered into SABG Table 1 in the planning section of the 

2014/2015 Behavioral Health Assessment and Plan will automatically populate cells 1 – 6 in the 

progress report table below. States are required to indicate whether each first-year performance 

target/outcome measurement identified in 6.b) below (from the 2014/2015 Plan) was “Achieved” or 

“Not Achieved” in Cell 7, Report of Progress toward Goal Attainment. If a target was not achieved, a 

detailed explanation must be provided, as well as the remedial steps proposed to meet the target.

SABG Table 1 - Priority Areas and Annual Performance Indicators – Progress Report

Priority Areas and Annual Performance Indicators 

1. Priority Area: 2. Priority Type (SAP, SAT, MHP, MHS):

3. Population(s) (SMI, SED, PWWDC, IVDUs, HIV EIS, TB, OTHER): 

4. Goal of the Priority Area:

5. Strategies to Attain the Goal:

6. Annual Performance Indicators to Measure Goal Success:

Indicator #1:

g) Baseline measurement (Initial data collected prior to the first-year target/outcome): 

h) First-year target/outcome measurement (Progress – end of SFY 2014):

i) Second-year target/outcome measurement (Final – end of SFY 2015):

j) Data source: 

k) Description of data:

l) Data issues/caveats that affect outcome measures:

7. Report of Progress toward Goal Attainment:

First-year target: ____ Achieved _____ Not Achieved (If not achieved, explain why.) 

Reason why target was not achieved, and changes proposed to meet target:
165

C. State Agency Expenditure Reports

States and Jurisdictions are requested to provide information regarding SA Block Grant and State 

funds expended for authorized activities to prevent and treat substance abuse and for related public 

health services, e.g., tuberculosis services and, if applicable, early intervention services for HIV. 

Please complete the tables described below: 

SABG Table 2 - State Agency Expenditure Report This table provides a report of SABG and state 

expenditures by the State Substance Abuse Authority during the State fiscal year immediately 

preceding the federal fiscal year for which the state is applying for funds. Expenditures to be reported 

are for authorized activities to prevent and treat substance abuse pursuant to section 1921 of Title 

XIX, Part B, Subpart II of the Public Health Service (PHS) Act (42 U.S.C. 300x-21), tuberculosis 

services and early intervention services, if applicable, pursuant to section 1924 of Title XIX, Part B, 

Subpart II of the PHS Act (42 U.S.C. 300x-24) and administration pursuant to section 1931 of Title 

XIX, Part B, Subpart II of the PHS Act (42 U.S.C. 300x-31(a)(1)(F)). In column A, Block Grant 

funds expended during that State fiscal year should be included regardless of the year of the Block 

Grant award. 

SABG Table 3 – SABG Expenditures by Service This table provides a report of SA Block Grant 

expenditures for specific services during the State fiscal year immediately preceding the federal fiscal 

year for which the state is applying for funds. All Block Grant funded services provided during that 

period should be included in this report, regardless of the year of the Block Grant award.

SABG Table 4 - SABG State Agency Expenditure Compliance Report This table provides a report of 

expenditures from the SA Block Grant Compliance Award for authorized activities to prevent and 

treat substance abuse. It covers the two-year obligation and expenditure period.

SABG Table 5a- SABG Primary Prevention Expenditures Checklist This table provides a report of 

prevention expenditures from the SAPT Block Grant Compliance Award for primary prevention 

services. 

SABG Table 5b- SABG Primary Prevention Expenditures by IOM Category This table provides a 

report of prevention expenditures by Institute of Medicine (IOM) categories from the SAPT Block 

Grant Compliance Award for primary prevention services.

SABG Table 5c - SABG Primary Prevention Targeted Priorities This requested table provides a 

report of actual State primary prevention priorities and special population categories on which the 

State expended primary prevention dollars from the SAPT Block Grant Compliance Award.

SABG Table 6 - SABG Resource Development Expenditure Checklist This table provides a report of 

expenditures from the SAPT Block Grant Compliance Award for resource development activities 

that are funded by and/or or conducted by the State Substance Abuse Authority.

SABG Table 7 – SABG Statewide Entity Inventory This table provides a report of the subrecipients 

of SA Block Grant funds including community- and faith-based organizations which provided 
166

substance abuse prevention activities and treatment services, as well as intermediaries/administrative 

service organizations. Table 7 excludes resource development expenditures.

SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse Prevention and 

Treatment This table provides a report of aggregate State expenditures by the State Substance 

Abuse Authority for authorized activities to prevent and treat substance abuse during the State fiscal 

year immediately preceding the federal fiscal year for which the state is applying for funds.

SABG Table 8b - Base and Maintenance of Effort for Statewide Non-Federal Expenditures for 

Tuberculosis to Individuals in Substance Use Disorder Treatment This table provides a report of 

Statewide expenditures of non-Federal funds expended for tuberculosis (TB) services made available 

to individuals in substance user disorder (SUD) treatment during the State fiscal year immediately 

preceding the federal fiscal year for which the state is applying for funds. 

SABG Table 8c - Base and Maintenance of Effort for Statewide Non-Federal Expenditures for HIV 

Early Intervention Services to Individuals in Substance Use Disorder Treatment This table provides 

a report of statewide expenditures of non-Federal funds during the State fiscal year immediately 

preceding the Federal fiscal year for which the state is applying for funds for HIV early intervention 

services provided to individuals in substance use disorder treatment at the sites at which such 

individuals were receiving SUD treatment services. 

SABG Table 8d - Base and Maintenance of Effort for Expenditures for Services to Pregnant Women 

and Women with Dependent Children This table provides a report of SA Block Grant and/or State 

expenditures for services demonstrating the Block Grant requirements designed to address the 

treatment and recovery support needs of substance using pregnant women and substance abusing 

women with dependent children during the State fiscal year immediately preceding the Federal fiscal 

year for which the state is applying for funds.
167

SABG Table 2 - State Agency Expenditure Report 

This table provides a report of SABG and State expenditures by the State Substance Abuse Authority during the State fiscal year immediately preceding 

the federal fiscal year for which the state is applying for funds for authorized activities to prevent and treat substance abuse. For detailed instructions, 

refer to those in the Block Grant Application System (BGAS). 

State Agency Expenditure Report

SABG Table 2 

State Identifier:

Report Period- From: To: 

(Include ONLY funds expended by the executive branch agency administering the Substance Abuse Block Grant

Source of Funds

ACTIVITY

(See instructions for using Row 1.)

A. 

Substance 

Abuse Block 

Grant

B.

Mental Health 

Block Grant. 

Block Grant

C. Medicaid

(Federal, State, 

and local)

D. Other 

Federal Funds 

(e.g., ACF (TANF), 

CDC, CMS 

(Medicare) 

SAMHSA, etc.)

E. State funds F. Local funds

(excluding local

Medicaid)

G. Other

1. Substance Abuse Prevention and Treatment

(Other than Primary Prevention)

a. Pregnant Women and Women with 

Dependent Children 

b. All Other

2. Primary Prevention

5. Tuberculosis Services

6. HIV Early Intervention Services

5. State Hospital

6. Other 24 Hour Care

7. Ambulatory/Community Non-24 Hour Care

8. Administration (excluding program / 

provider level

9. Total
168

SABG Table 3 (Requested) - SA Block Grant Expenditures by Service

This table provides a report of SABG and state expenditures during the state fiscal year immediately preceding the federal fiscal year for which the 

State is applying for funds.

SABG Expenditures by Service

SABG Table 3 

State Identifier:

Report Period- From: To:

Service No. of Unduplicated Individuals Unit Type Unit Quantity SABG Expenditures

Healthcare Home/Physical Health

General and specialized outpatient medical services

Acute Primary care

General Health Screens, Tests and Immunizations

Comprehensive Care Management

Care coordination and Health Promotion

Comprehensive Transitional Care

Individual and Family Support

Referral to Community Services

Prevention 

Prevention Including Promotion

Screening, Brief Intervention and Referral to Treatment 

Brief Motivational Interviews $

Screening and Brief Intervention for Tobacco Cessation $

Parent Training $

Facilitated Referrals $

Relapse Prevention/Wellness Recovery Support $

Warm Line $

Substance Abuse Primary Prevention

Classroom and/or small group sessions (Education)

Media campaigns (Information Dissemination) Media campaigns (Information 

Dissemination)

$

Systematic Planning/Coalition and Community Team Building(Community Based 

Process)

Parenting and family management (Education)

Education programs for youth groups (Education) $
169

SABG Expenditures by Service

SABG Table 3 

State Identifier:

Report Period- From: To:

Service No. of Unduplicated Individuals Unit Type Unit Quantity SABG Expenditures

Community Service Activities (Alternatives) $

Student Assistance Programs (Problem Identification and Referral) $

Employee Assistance programs (Problem Identification and Referral) $

Community Team Building (Community Based Process) $

Promoting the establishment or review of alcohol, tobacco, and drug use policies 

(Environmental) 

$

Engagement Services

Assessment

Specialized Evaluations (Psychological and Neurological)

Service Planning (including crisis planning)

Consumer/Family Education

Outreach

Outpatient Services

Individual evidenced based therapies

Group therapy

Family therapy 

Multi-family therapy

Consultation to Caregivers

Medication Services

Medication management

Pharmacotherapy (including MAT)

Laboratory services

Community Support (Rehabilitative)

Parent/Caregiver Support

Skill building (social, daily living, cognitive)

Case management

Behavior management

Supported employment

Permanent supported housing

Recovery housing

Therapeutic mentoring

Traditional healing services
170

SABG Expenditures by Service

SABG Table 3 

State Identifier:

Report Period- From: To:

Service No. of Unduplicated Individuals Unit Type Unit Quantity SABG Expenditures

Recovery Supports 

Peer Support

Recovery Support Coaching

Recovery Support Center Services

Supports for Self Directed Care

Other Supports (Habilitative)

Personal care

Homemaker

Respite

Supported Education

Transportation

Assisted living services

Recreational services

Trained behavioral health interpreters

Interactive communication technology devices

Intensive Support Services

Substance abuse intensive outpatient (IOP)

Partial hospital

Assertive Community Treatment

Intensive home based services

Multi-systemic therapy

Intensive Case Management 

Out of Home Residential Services

Crisis residential/stabilization

Clinically Managed 24 Hour Care (SA)

Clinically Managed Medium Intensity Care (SA) 

Adult Substance Abuse Residential

Adult Mental Health Residential 

Youth Substance Abuse Residential Services

Children's Residential Mental Health Services 

Therapeutic foster care
171

SABG Expenditures by Service

SABG Table 3 

State Identifier:

Report Period- From: To:

Service No. of Unduplicated Individuals Unit Type Unit Quantity SABG Expenditures

Acute Intensive Services

Mobile crisis

Peer based crisis services

Urgent care

23 hr. observation bed

Medically Monitored Intensive Inpatient (SA) 

24/7 crisis hotline services

Other (please list)
172

SABG Table 4 - State Agency SABG Expenditure Compliance Report

This table provides a description of SA Block Grant expenditures for authorized activities to prevent and treat substance abuse from the fiscal year 

2012 award. For detailed instructions, refer to those in BGAS. 

State Agency SABG Expenditure Compliance Report

SABG Table 4 FY 2012 SA Block Grant Award

State Identifier: 

Expenditure Category

1. Substance Abuse Prevention* and Treatment

2. Primary Prevention

3. HIV Early Intervention Services**

4. Tuberculosis Services

5. Administration (excluding program / provider level)

6. Total

* Prevention other than Primary Prevention

 ** By HIV Designated States
173

SABG Table 5a - Primary Prevention Expenditures Checklist

There are six primary prevention strategies typically funded by principal agencies administering the SAPT Block Grant. Expenditures within each 

of the six strategies or Institute of Medicine Model (IOM) should be directly associated with the cost of completing the activity or task. For 

example, information dissemination may include the cost of developing pamphlets, the time of participating staff and/or the cost of public service 

announcements, etc. If a State or Jurisdiction employs strategies not covered by these six categories, please report them under “Other”, each in a 

separate row.

Section 1926 – Tobacco: Costs associated with the Synar Program Pursuant to the January 19, 1996 federal regulation “Tobacco Regulation for 

Substance Abuse Prevention and Treatment Block Grants, Final Rule” (45 C.F.R. §96.130), a state may not use the Block Grant to fund the 

enforcement of its statute, except that it may expend funds from its primary prevention set aside of its Block Grant allotment under 45 C.F.R. 

§96.124(b)(1) for carrying out the administrative aspects of the requirements,y such as the development of the sample design and the conducting of 

the inspections. States should include an non-SABG funds that were alloted for Synar activities in the appropriate columns under 7 below.

SABG Primary Prevention Expenditures Checklist

SABG Table 5a 

State Identifier:

Report Period- From: To:

Strategy A. 

IOM Target

B. 

SAPT Block Grant

C. 

Other Federal

D. 

State

E. 

Local

F. Other

1. Information Dissemination Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

Unspecified $ $ $ $ $

2. Education Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

Unspecified $ $ $ $ $

3. Alternatives Universal $ $ $ $ $

Selected $ $ $ $ $
174

Indicated $ $ $ $ $

Unspecified $ $ $ $ $

4. Problem Identification and 

Referral

Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

Unspecified $ $ $ $ $

5. Community-Based Processes Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

6. Environmental Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

Unspecified $ $ $ $ $

7. Section 1926-Tobacco Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

8. Other Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

9. Suicide Prevention $ $ $ $ 

10. Total $ $ $ $ $

 

*Please lit all sources, if possible (e.g.., Centers for Disease Control and Prevention, Block Grant, foundations, etc.)
175

SABG Table 5b - SABG Primary Prevention Expenditures by Institute of Medicine (IOM) Categories 

The State or Jurisdiction must complete SABG Table 5b if it chooses to report substance abuse 

primary prevention activities utilizing the IOM Model of Universal, Selective and Indicated. Indicate 

how much funding supported each of the IOM classifications of Universal, Selective, or Indicated. 

Include all funding sources (e.g., Centers for Disease Control and Prevention Block Grant, 

foundations). For detailed instructions, refer to those in the Block Grant Application System 

(BGAS). 

SABG Primary Prevention Expenditures by IOM Category

SABG Table 5B 

State Identifier:

Report Period- From: To:

Activity

FY 2012 SA 

Block Grant 

Award

Other Federal State Funds Local Funds Other

Universal Direct $ $ $ $ $

Universal Indirect $ $ $ $ $

Selective $ $ $ $ $

Indicated $ $ $ $ $

Column Total $ $ $ $ $

Total SABG Award $ $

Planned Primary 

Prevention

Percentage

% %
176

SABG Table 5c (Requested) - SABG Primary Prevention Targeted Priorities

The purpose of the first table is for the State or Jurisdiction to identify the substance and/or 

categories of substances it identified through its needs assessment and then addressed with Primary 

Prevention set-aside dollars from the FY 2012 SA Block Grant award. The purpose of the second 

table is to identify each special population the State or Jurisdiction selected as a priority for Primary 

Prevention set-aside expenditures.

SABG Primary Prevention Targeted Priorities-1

Targeted Substances Yes No

Alcohol

Tobacco

Marijuana

Prescription Drugs

Cocaine

Heroin

Inhalants

Methamphetamine

Synthetic Drugs (i.e. Bath salts, 

Spice, K2)

SABG Primary Prevention Targeted Priorities-2 

Targeted Populations Yes No

Students in College

Military Families

LGBTQ

American Indians/Alaska 

Natives

African American

Hispanic

Homeless

Native Hawaiian/Other Pacific 

Islanders

Asian

Rural

Underserved Racial and Ethnic 

Minorities
177

SABG Table 6 - SABG Resource Development Expenditures Checklist

If the State or Jurisdiction funded resource development activities with the SABG FY 2012 award, it is required to complete this table. For detailed 

instructions, refer to those in BGAS. 

SABG Resource Development Expenditures Checklist

SABG Table 6 

State Identifier:

Report Period- From: To:

Activity A. Treatment B. Prevention C. Additional 

Combined

D. Total

1. Planning, coordination, and needs assessment $ $ $ $

2. Quality Assurance $ $ $ $

3. Training (post-employment) $ $ $ $

4. Education (pre-employment) $ $ $ $

5. Program development $ $ $ $

6. Research and evaluation $ $ $ $

7. Information Systems $ $ $ $

8. Total

 
178

SABG Table 7 – State Entity Inventory 

This table provides a report of the subrecipients of SA Block Grant funds including community- and faith-based organizations which provided 

substance abuse prevention activities and treatment services, as well as intermediaries/administrative service organizations. Table 7 excludes 

resource development expenditures. For detailed instructions, see those in BGAS.

Statewide Entity Inventory

SABG Table 7 

State Identifier:

Report Period- From: To:

Source of Funds

SAPT Block Grant CMHS Block Grant

A B B D E F G H

Entity

Number 

I-BHS ID 

(formerly

I-SATS)

Area 

Served 

(Statewide 

or SubState 

Planning 

Area)

Provider/Program 

Name

Street 

Address

City State Zip All SA

Block 

Grant 

Funds

Prevention 

(other than 

primary 

prevention) 

and 

Treatment

Services 

Pregnant 

Women 

and 

Women 

with 

Dependent 

Children

Primary 

Prevention

Early 

Intervention 

Services for 

HIV

Adults 

serious 

mental 

illness

Children 

with a 

serious 

emotional 

disturbance

NonDirect 

Services

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $
179

SABG Table 8a - Maintenance of Effort for State Expenditures for Substance Abuse Prevention and Treatment

This Maintenance of Effort table provides a description of non-Federal expenditures for authorized activities to prevent and treat substance abuse 

flowing through the Single State Agency (SSA) during the State fiscal year immediately preceding the federal fiscal year for which the state is 

applying for funds.

For detailed instructions, see those in BGAS.

SABG Table 8a Total Single State Agency (SSA) Expenditures for Substance Abuse Prevention and Treatment

State Identifier:

Report Period- From: To:

Period 

(A)

Expenditures 

(B)

B1 (2012) + B2 (2013)

2

(C)

SFY 2012

(1)

SFY 2013

(2)

SFY 2014

(3)

Are the expenditure amounts reported in Column B “actual” expenditures for the fiscal years involved?

Yes No

SFY 2012

SFY 2013

SFY 2014

If any estimated expenditures are provided, please indicate when “actual” expenditure data will be submitted to SAMHSA: ___/___/_____

mm/dd/yyyy

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

Yes____ No ___ If yes, specify the amount and the State fiscal year ___________

Did the State or Jurisdiction include these funds in previous year MOE calculations? Yes___ No___

When did the State or Jurisdiction submit an official request to SAMHSA to exclude these funds from the MOE calculations? ___/___/_____

 mm/dd/yyyy
OMB No. 0930-0080

SABG Table 8b - Statewide Non-Federal Expenditures for Tuberculosis to Individuals in Substance Use Disorder (SUD) Treatment 

This Maintenance of Effort table provides a report of all statewide, non-Federal funds expended on Tuberculosis (TB) services to individuals in 

substance use disorder treatment during the State fiscal year immediately preceding the federal fiscal year for which the state is applying for funds.

Statewide Non-Federal Expenditures for Tuberculosis Services to Individuals in SUD Treatment

SABG Table 8b 

State Identifier: 

BASE

Period

Total of All 

State Funds 

Spent on TB 

Services

(A)

% of TB Expenditures 

Spent on Individuals in 

Substance Use 

Disorder Treatment

(B)

Total State Funds Spent 

on Individuals in 

Substance Use 

Disorders Treatment 

(AxB)

(C)

Average of

Columns

C1 and C2=

C1 + C2

2

(MOE BASE)

(D)

SFY 1991 (1)

SFY 1992 (2)

MAINTENANCE

Period

Total of All 

State Funds 

Spent on TB 

Services

(A)

% of TB Expenditures 

Spent on Individuals in 

Substance Use 

Disorder Treatment

(B)

Total State Funds Spent 

on Individuals in 

Substance Use 

Disorders Treatment 

(A x B)

(C)

SFY 2014 (3)
OMB No. 0930-0080

SABG Table 8c -Statewide Non-Federal Expenditures for HIV Early Intervention Services to Individuals in Substance Use Disorder Treatment

This Maintenance of Effort table is for “designated States” to report all statewide, non-Federal funds expended on HIV EIS services to individuals 

in substance use disorder treatment during the State fiscal year immediately preceding the federal fiscal year for which the state is applying for 

funds.

Enter the federal fiscal year in which your State first became a designated State. Federal Fiscal Year ____. 

Enter the prior 2 years’ expenditure data in A1 and A2. Compute the average of the amounts in boxes A1 and A2. Enter the resulting average 

(Base) in box B2.

Statewide Non-Federal Expenditures for HIV Early Intervention Services

to Individuals in Substance Use Disorder Treatment

SABG Table 8c 

State Identifier:

BASE

Period Total of All State Funds 

Spent on Early 

Intervention Services for 

HIV

(A)

Average of 

Columns 

A1 and A2

A1+A2

2

(MOE Base)

(B)

(1) SFY ____

(2) SFY____ 

MAINTENANCE

Period Total of All State Funds Spent on Early Intervention 

Services for HIV

(A)

(3) SFY 2014
OMB No. 0930-0080

SABG Table 8d - Expenditures for Services to Pregnant Women and Women with Dependent Children

This Maintenance of Effort table provides a report of all statewide, non-Federal funds expended on Tuberculosis (TB) services to individuals in 

substance use disorder treatment during the State fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. G Table 8c SABG Table 8c SABG Table 8c 

SABG Table 8c 

For detailed instructions, see those in BGAS.

Expenditures for Services to Pregnant Women and Women with Dependent Children

SABG Table 8d 

State Identifier:

Report Period- From: To:

Period Total Women’s Base

(A)

Total Expenditures

(B)

1994

2012

2013

2014
183

D. Populations and Services Report

States and Jurisdictions are required to provide information regarding individuals that are served by 

the State Substance Abuse Authority in SABG Tables 9 through 13. 

SABG Table 9 - Prevention Strategy Report This table requires additional information (pursuant to

Section 1929 of Title XIX, Part B, Subpart II of the PHS Act) about the primary prevention activities 

conducted by the entities listed on SABG Table 7, State Entity Inventory, Column D. It seeks further 

information on the specific strategies and activities being funded by the principal agency of the State

which address the sub-populations at risk for alcohol, tobacco, and other drug (ATOD) use/abuse.

SABG Table 10 - Treatment Utilization Matrix This table is intended to capture the count of 

persons with initial admissions and subsequent admission(s) to an episode of care (as defined in the 

Drug and Alcohol Services Information System (DASIS) Treatment Episode Data Set (TEDS) 

standards (see http://oas.samhsa.gov/dasis.htm#teds2) during the State fiscal year immediately 

preceding the federal fiscal year for which the state is applying for funds.

SABG Table 11 - Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use. 

This table provides an aggregate profile of the unduplicated number of admissions and persons for 

services funded through the SABG during the State fiscal year immediately preceding the federal 

fiscal year for which the state is applying for funds. States and Jurisdictions are to provide this 

information on all programs by age, gender, and race/ethnicity. States and Jurisdictions are to report 

whether the values reported come from a client-based system(s) with unique client identifiers.

SABG Table 12 – SABG HIV Designated States Early Intervention Services This table requires 

“designated States”, as defined in section 1924(b) of Title XIX, Part B, Subpart II of the PHS Act (42 

U.S.C. 300x-24(b)), to provide information on Early Intervention Services for HIV testing and 

referral provided during the State fiscal year immediately preceding the federal fiscal year for which 

the state is applying for funds.

SABG Table 13 - Charitable Choice This table requires States and Jurisdictions to provide 

information regarding compliance with section 1955 of Title XIX, Part B, Subpart III of the PHS Act 

(42 U.S.C. 300x-65) and the Charitable Choice Provisions and Regulations; Final Rule (42 C.F.R. 

Part 54) during the State fiscal year immediately preceding the federal fiscal year for which the state 

is applying for funds.
 SABG Table 9 - Prevention Strategy Report 

This table requires additional information (pursuant to Section 1929 of Title XIX, Part B, Subpart II of the PHS Act) about the primary 

prevention activities conducted by the entities listed on SABG Table 7. For detailed instructions, see those in BGAS.

Prevention Strategy Report Risk-Strategies

SABG Table 9

Report Period- From: To:

State Identifier

Column A (Risks) Column B (Strategies) Column C (Providers)

Children of Substance Abusers [1]

Pregnant Women / Teens [2]

Drop-Outs [3]

Violent and Delinquent Behavior [4]

Mental Health Problems [5]

Economically Disadvantaged [6]

Physically Disabled [7]

Abuse Victims [8]

Already Using Substances [9]

Homeless and/or Runaway Youth [10]

Other, Specify [11]
SABG Table 10 – Treatment Utilization Matrix

This table is intended to capture the count of persons with initial admissions and subsequent admission(s) to an episode of care. For detailed 

instructions, see those in BGAS.

For detailed instructions, see those in BGAS.

SABG Table 10

Report Period- From: To: Treatment Utilization Matrix

Number of Admissions ≥ 

Number of Persons Served Costs per Person

Level Of Care

Number

of Admissions

(A)

Number of

Persons Served

(B)

Mean Cost of Services

(C)

Median Cost of Services

(D)

Standard Deviation of 

Cost 

(E)

Detoxification (24-Hour Care)

1. Hospital Inpatient $ $ $

2. Free-Standing Residential $ $ $

Rehabilitation/Residential

3. Hospital Inpatient $ $ $

5. Short-term (up to 30 days) $ $ $

5. Long-term (over 30 days) $ $ $

Ambulatory (Outpatient)

6. Outpatient $ $ $

7. Intensive Outpatient $ $ $

8. Detoxification $ $ $

Opioid Replacement Therapy

9. Opioid Replacement Therapy $ $ $

10. ORT Outpatient
SABG Table 11 - Unduplicated Count of Persons Served for Alcohol and Other Drug Use 

This table provides an aggregate profile of the unduplicated number of admissions and persons for services funded through the SABG. For 

detailed instructions, see those in BGAS.

SABG Table 11

Report Period- From: To::

State Identifier:

Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use in State Funded Services by Age, Sex and Race/Ethnicity

Sex and Race/Ethnicity

Age A. Total B. White C. Black or 

African 

American

D. Native 

Hawaiian/

Other Pacific 

Islander

E. Asian F. American 

Indian/Alaskan 

Native

G. More Than 

One Race 

Reported

H. Unknown I. Not Hispanic 

or Latino

J. Hispanic or 

Latino

M F M F M F M F M F M F M F M F M F

1. 17 and 

under

2. 18-24

3. 25-44

4. 45-64

5. 65 and 

over

5. Total

7. Pregnant 

Women

Numbers of Persons Served 

who were admitted in a 

Period Prior to the 12 month 

reporting Period

Number of persons served 

outside of the levels of care 

described on SABG Table 10
SABG Table 12 - SABG Human Immunodeficiency Virus (HIV) Early Intervention Services in Designated States 

For detailed instructions, see those in BGAS.

SABG Table 12

Report Period- From: To::

State Identifier

Early Intervention Services for Human Immunodeficiency Virus (HIV) 

1. Number of SAPT HIV EIS programs funded in the State: Statewide:_____ Rural:_____

2. Total number of individuals tested through SAPT HIV EIS funded 

programs:

3. Total number of HIV tests conducted with SAPT HIV EIS funds:

4. Total number of tests that were positive for HIV:

5. Total number of individuals who prior to the 12-month reporting 

period were unaware of their HIV infection:

6. Total number of HIV-infected individuals who were diagnosed and 

referred into treatment and care during the 12-month reporting period

Identify barriers, including State laws and regulations, that exist in carrying out HIV testing services:
SABG Table 13 - Charitable Choice

Under Charitable Choice, States, local governments, and religious organizations, such as SAMHSA 

grant recipients, must: (1) ensure that religious organizations that are providers provide to all 

potential and actual program beneficiaries (services recipients) notice of their right to alternative 

services; (2) ensure that religious organizations that are providers refer program beneficiaries to 

alternative services; and (3) fund and/or provide alternative services. The term “alternative services” 

means services determined by the State to be accessible and comparable and provided within a 

reasonable period of time from another substance abuse provider (“alternative provider”) to which 

the program beneficiary (services recipient) has no religious objection. The purpose of this table is 

to document how the State is complying with these provisions.

Notice to Program Beneficiaries – Check all that apply:

□ Used model notice provided in final regulations.

□ Used notice developed by State (please attach a copy to the Report)

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

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

Referrals to Alternative Services – Check all that apply:

□ State has developed specific referral system for this requirement.

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

□ SAMHSA’s Treatment Facility Locator is used to help identify providers.

□ Other networks and information systems are used to help identify providers. 

□ State maintains record of referrals made by religious organizations that are providers.

 Enter the total number of referrals to other substance abuse providers (“alternative 

providers”) necessitated by religious objection, as defined above, made during the State 

fiscal year immediately preceding the federal fiscal year for which the state is applying 

for funds. Provide the total only. No information on specific referrals is required.

Provide a brief description (one paragraph) of any training for local governments and/or faith-based 

and/or community organizations that are providers on these requirements.
189

E. Performance Data and Outcomes

SAMHSA is interested in demonstrating program accountability and efficacy through the National 

Outcome Measures (NOMs). The NOMs are intended to document the performance of federally 

supported programs and systems of care.

Treatment Performance Measures

SABG Table 14 Employment/Education Status This table describes the status of adult clients 

served by the public substance use disorder treatment system in terms of employment and education 

status. The Employment\Education Status Form seeks information on clients who are employed or 

who are students (full-time or part-time) (prior 30 days) at admission and discharge.

SABG Table 15 Stability of Housing This table requests information regarding the number of 

individuals in a Stable Living Environment as collected by the most recent assessment in the 

reporting period. Specifically, information is collected on the individual’s last known living 

situation.

SABG Table 16 Criminal Justice Involvement This table requests information regarding the 

clients’ involvement in the criminal justice system. Specifically, the table requests information to 

measure the change in number of arrests over time.

SABG Table 17 Change in Abstinence–Alcohol Use This table seeks information regarding 

alcohol abstinence. Specifically, information is collected on the number of clients with no alcohol 

use (all clients regardless of primary problem) at admission and discharge.

SABG Table 18 Change in Abstinence – Other Drug Use This table collects information regarding 

clients’ change in abstinence with drugs of abuse other than alcohol. This table seeks to collect 

information on clients with no other drug use (all clients regardless of primary problem) at admission 

and discharge.

SABG Table 19 Change in Social Support of Recover This table seeks to measure the change in 

clients’ social support or recovery. Specifically, this form collects information regarding the number 

of clients participating in self help groups at admission and discharge

SABG Table 20 Retention This table collects information regarding retention. Specifically, this 

table collects information regarding the length of stay of clients completing treatment.

Prevention Performance Measures

SABG Table 22 Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure: Perception 

of Risk/Harm of Use. This table seeks information regarding the individuals’ perceived risk of 

harming themselves with alcohol, tobacco and other drugs.
 190

SABG Table 23 Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Age of 

First Use. This table seeks information regarding the age of first use of alcohol, cigarettes and other 

drugs.

SABG Table 24 Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Perception 

of Disapproval/Attitudes. This table seeks information regarding the general public perception or 

attitude regarding use of alcohol, cigarettes and other drugs. 

SABG Table 25 Employment/Education; Measure: Perception of Workplace Policy. This table 

reports the percent of individuals who would be more likely to work for an employer conducting 

random drug and alcohol tests.

SABG Table 26 Employment/Education; Measure: Average Daily School Attendance Rate. This 

table collects information regarding the average daily school attendance. 

SABG Table 27 Crime and Criminal Justice; Measure: Alcohol-Related Traffic Fatalities. This 

table collects information regarding the number of alcohol-related traffic fatalities divided by the 

total number of traffic fatalities and multiplied by 100.

SABG Table 28 Crime and Criminal Justice; Measure: Alcohol and Drug Related Arrests. This 

table collects information regarding alcohol- and drug-related arrests. 

SABG Table 29 Social Connectedness; Measure: Family Communications around Drug and 

Alcohol Use. This table provides information regarding the percent of youth reporting having talked 

with a parent and the percent of parents reporting that they have talked to their child around alcohol 

and drug use.

SABG Table 30 Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or Listening 

to a Prevention Message. This table collects information regarding the percent of youth reporting 

having been exposed to prevention message.

SABG Table 31 Individual-Based Programs and Strategies; Measure: Number of Persons Served 

By Age, Gender, Race, and Ethnicity. This table provides information on the number of persons 

served by individual-based programs and strategies. This includes practices and strategies with 

identifiable goals designed to change behavioral outcomes among a definable population or within a 

definable geographic area. 

SABG Table 32 Population-Based Programs and Strategies; Measure: Number of Persons Served 

By Age, Gender, Race, And Ethnicity. This table provides information regarding the number of 

persons by age, gender, race, and ethnicity that participated in population-based programs. 

Population-based programs and strategies include planned and deliberate goal-oriented practices, 

procedures, processes, or activities that have identifiable outcomes achieved with a sequence of steps 

subject to monitoring and modification.

SABG Table 33 Number of Persons Served by Type of Intervention. This table seeks to measure 

information on access and capacity of intervention programs. Specifically, this form collects 

information on the number of persons served by type of Intervention. Interventions include 

activities, practices, procedures, processes, programs, services, and strategies. 
 191

SABG Table 34 Number of Evidence-Based Programs by Types of Intervention. This table 

collects information on the number of evidence-based programs and strategies by type of 

intervention.

SABG Table 35 Number of Evidence-based Programs and Strategies, and Total SA Block Grant 

Funds Spent on Evidence-Based Programs/ Strategies.

Prevention Attachments A, B and C – Information on completing the State request for data 

substitution application and the State substitution appeal forms (below) follows. These forms should 

be completed if a State wishes to substitute data collected through a State effort for the prevention 

pre-populated National Outcome Measures (NOMs) on the NOMs Data Collection and Reporting 

Forms. If the State is requesting substitutions for more than one NOM, one application should be 

completed for all NOMs for which a substitution is requested. A state may also appeal a decision 

that the State will not be allowed to substitute pre-populated with the States data.

SABG Table 36 (Optional Worksheet) Program/Strategy Detail for Computing the Total Number 

of Evidence-based Programs and Strategies, and for Reporting Total SA Block Grant Funds Spent on 

Substance Abuse Prevention Evidence-Based Programs and Strategies. This table supports the 

computation of the total number of evidence-based programs and strategies and the total SA Block 

Grant funds spent on substance abuse prevention evidence-based programs and strategies.
 192

SABG Table 14 – TREATMENT PERFORMANCE MEASURE

EMPLOYMENT\EDUCATION STATUS (From Admission to Discharge) 

Most recent year for which data are available: _____________

Employment\Education Status – Clients employed or student (full-time or parttime) (prior 30 days) at admission vs. discharge 

Admission

Clients (T1)

Discharge 

Clients (T2)

Number of clients employed or student (full-time and part-time) [numerator] 

Total number of clients with non-missing values on employment\student status 

[denominator]

Percent of clients employed or student (full-time and part-time) 
193

State Description of Employment\Education Status Data Collection (SABG Table 15)

STATE CONFORMANCE TO 

INTERIM STANDARD

State Description of Employment\Education Data Collection (SABG Table 15):

States should detail exactly how this information is collected. Where data and methods vary 

from interim standard, variance should be described.

DATA SOURCE What is the source of data for SABG Table 15 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ 

Administrative data source □ Other Specify ___________________

EPISODE OF CARE How is the admission/discharge basis defined for SABG Table 15 (Select one) □ Admission is 

on the first date of service, prior to which no service has been received for 30 days AND 

discharge is on the last date of service, subsequent to which no service has been received for 30 

days 

□ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is 

on the last date of service in a Program/Service Delivery Unit

□ Other Specify ___________________________________________

_________________________________________________________

DISCHARGE DATA 

COLLECTION

How was discharge data collected for SABG Table 15 (select all that apply)

□ Not applicable, data reported on form is collected at time period other than discharge→ 

Specify:

□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- 

□ admission □ discharge □ other ______ 

□ Discharge data is collected for the census of all (or almost all) clients who were admitted to 

treatment □ Discharge data is collected for a sample or all clients who were admitted to 

treatment □ Discharge records are directly collected (or in the case of early dropouts) are created 

for all (or almost all) clients who were admitted to treatment 

□ Discharge records are not collected for approximately ___ % of clients who were admitted for 

treatment 

RECORD LINKING Was the admission and discharge data linked for table 15 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier 

(UCID)

Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social 

Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of 

birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific 

unique ID 

□ No, State Management Information System does not utilize UCID that allows comparison of 

admission and discharge data on a client specific basis (data developed on a cohorts basis) or 

State relied on other data sources for post admission data □ No, admission and discharge records 

were matched using probabilistic record matching.

IF DATA IS UNAVAILABLE If data is not reported, why is State unable to report (select all that apply): 

□ Information is not collected at admission □ Information is not collected at discharge □ 

Information is not collected by the categories requested □ State collects information on the 

indicator area but utilizes a different measure.

DATA PLANS IF DATA IS NOT 

AVAILABLE

State must provide time-framed plans for capturing employment\student status data on all clients, 

if data is not currently available. Plans should also discuss barriers, resource needs and estimates 

of cost.
194

SABG Table 15–TREATMENT PERFORMANCE MEASURE 

STABILITY OF HOUSING (From Admission to Discharge)

Most recent year for which data are available: _____________

Clients living in a stable living situation (prior 30 days) at admission vs. discharge Admission

Clients (T1)

Discharge 

Clients (T2)

Number of clients living in a stable situation [numerator] 

Total number of clients with non-missing values on living arrangements [denominator] 

Percent of clients in a stable living situation 
195

SABG Table 16– TREATMENT PERFORMANCE MEASURE 

CRIMINAL JUSTICE INVOLVEMENT (From Admission to Discharge)

Most recent year for which data are available: _____________

Clients without arrests (any charge) (prior 30 days) at admission vs. discharge Admission

Clients 

(T1)

Discharge 

Clients 

(T2)

Number of Clients without arrests [numerator] 

Total number of clients with non-missing values on arrests [denominator]

Percent of clients without arrests 
 

196

State Description of Criminal Involvement Data Collection (SABG Table 16)

STATE CONFORMANCE TO 

INTERIM STANDARD

State Description of Criminal Involvement Data Collection (SABG Table 16): 

States should detail exactly how this information is collected. Where data and methods vary 

from interim standard, variance should be described.

DATA SOURCE What is the source of data for SABG Table 16 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ □ collateral source □ 

Administrative data source □ Other Specify ___________________

EPISODE OF CARE How is the admission/discharge basis defined for SABG Table 16 (Select one) □ Admission is 

on the first date of service, prior to which no service has been received for 30 days AND 

discharge is on the last date of service, subsequent to which no service has been received for 30 

days 

□ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is 

on the last date of service in a Program/Service Delivery Unit

□ Other Specify ___________________________________________

_________________________________________________________

DISCHARGE DATA 

COLLECTION

How was discharge data collected for SABG Table 16 (select all that apply)

□ Not applicable, data reported on form is collected at time period other than discharge→ 

Specify:

□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- 

□ admission □ discharge □ other ______ 

□ Discharge data is collected for the census of all (or almost all) clients who were admitted to 

treatment □ Discharge data is collected for a sample or all clients who were admitted to 

treatment □ Discharge records are directly collected (or in the case of early dropouts) are 

created for all (or almost all) clients who were admitted to treatment 

□ Discharge records are not collected for approximately ___ % of clients who were admitted 

for treatment 

RECORD LINKING Was the admission and discharge data linked for SABG Table 16 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using an Unique Client 

Identifier (UCID)

Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ 

Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as 

date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entityspecific unique ID 

□ No, State Management Information System does not utilize UCID that allows comparison of 

admission and discharge data on a client specific basis (data developed on a cohorts basis) or 

State relied on other data sources for post admission data □ No, admission and discharge 

records were matched using probabilistic record matching.

IF DATA IS UNAVAILABLE

If data is not reported, why is State unable to report (select all that apply): □ Information is not 

collected at admission □ Information is not collected at discharge □ Information is not 

collected by the categories requested □ State collects information on the indicator area but 

utilizes a different measure.

DATA PLANS IF DATA IS 

NOT AVAILABLE

State must provide time-framed plans for capturing criminal justice involvement status data on 

all clients, if data is not currently available. Plans should also discuss barriers, resource needs 

and estimates of cost.
197

SABG Table 17– PERFORMANCE MEASURE 

CHANGE IN ABSTINENCE – ALCOHOL USE (From Admission to Discharge)

Most recent year for which data are available: _____________

Alcohol Abstinence – Clients with no alcohol use (all clients regardless of primary problem) (use Alcohol 

Use in last 30 days field) at admission vs. discharge. Admission

Clients 

(T1)

Discharge 

Clients 

(T2)

Number of clients abstinent from alcohol [numerator] 

Total number of clients with non-missing values on “used any alcohol” variable [denominator] 

Percent of clients abstinent from alcohol 

(1) If State does not have a "used any alcohol" variable, calculate instead using frequency of use variables 

for all primary, secondary, or tertiary problem codes in which the coded problem is Alcohol (e.g. ,TEDS 

Code 02)
198

State Description of Alcohol Use Data Collection (SABG Table 17)

STATE 

CONFORMANCE TO 

INTERIM STANDARD

State Description of Alcohol Use Data Collection (SABG Table 17): 

State should detail exactly how this information is collected. Where data and methods vary 

from interim standard, variance should be described.

DATA SOURCE What is the source of data for SABG Table 17 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test 

or other biological assay □ collateral source

□ Administrative data source □ Other Specify ___________________

EPISODE OF CARE How is the admission/discharge basis defined for SABG Table 17 (Select one) □ Admission is 

on the first date of service, prior to which no service has been received for 30 days AND 

discharge is on the last date of service, subsequent to which no service has been received for 30 

days 

□ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is 

on the last date of service in a Program/Service Delivery Unit

□ Other Specify ___________________________________________

DISCHARGE DATA 

COLLECTION

How was discharge data collected for SABG Table 17 (select all that apply)

□ Not applicable, data reported on form is collected at time period other than discharge→ 

Specify:

□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- 

□ admission □ discharge □ other ______ 

□ Discharge data is collected for the census of all (or almost all) clients who were admitted to 

treatment □ Discharge data is collected for a sample or all clients who were admitted to 

treatment □ Discharge records are directly collected (or in the case of early dropouts) are 

created for all (or almost all) clients who were admitted to treatment 

□ Discharge records are not collected for approximately ___ % of clients who were admitted 

for treatment 

RECORD LINKING Was the admission and discharge data linked for SABG Table 17 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using an Unique Client 

Identifier (UCID)

Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ 

Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as 

date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entityspecific unique ID 

□ No, State Management Information System does not utilize UCID that allows comparison of 

admission and discharge data on a client specific basis (data developed on a cohorts basis) or 

State relied on other data sources for post admission data □ No, admission and discharge 

records were matched using probabilistic record matching.

IF DATA IS 

UNAVAILABLE

If data is not reported, why is State unable to report (select all that apply): □ Information is not 

collected at admission □ Information is not collected at discharge □ Information is not 

collected by the categories requested □ State collects information on the indicator area but 

utilizes a different measure.

DATA PLANS IF DATA 

IS NOT AVAILABLE

State must provide time-framed plans for capturing abstinence - alcohol use status data on all 

clients, if data is not currently available. Plans should also discuss barriers, resource needs and 

estimates of cost.
199

SABG Table 18 – PERFORMANCE MEASURE

CHANGE IN ABSTINENCE -- OTHER DRUG USE (From Admission to Discharge) 

Most recent year for which data are available: _____________

Drug Abstinence – Clients with no drug use (all clients regardless of primary problem) (use Any Drug 

Use in last 30 days field) at admission vs. discharge. 

Admission

Clients (T1)

Discharge 

Clients (T2)

Number of Clients abstinent from illegal drugs [numerator] 

Total number of clients with non-missing values on “used any drug” variable [denominator] 

Percent of clients abstinent from drugs 

(2) If State does not have a "used any drug" variable, calculate instead using frequency of use variables for all primary, secondary, or 

tertiary problem codes in which the coded problem is Drugs (e.g., TEDS Codes 03-20)
200

State Description of Other Drug Use Data Collection (SABG Table 18)

STATE CONFORMANCE TO 

INTERIM STANDARD

State Description of Other Drug Use Data Collection (SABG Table 18): 

States should detail exactly how this information is collected. Where data and methods vary 

from interim standard, variance should be described.

DATA SOURCE What is the source of data for SABG Table 18 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ □ urinalysis, blood test 

or other biological assay □ collateral source

□ Administrative data source □ Other Specify ___________________

EPISODE OF CARE How is the admission/discharge basis defined for SABG Table 18 (Select one) □ Admission is 

on the first date of service, prior to which no service has been received for 30 days AND 

discharge is on the last date of service, subsequent to which no service has been received for 30 

days 

□ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is 

on the last date of service in a Program/Service Delivery Unit

□ Other Specify ___________________________________________

DISCHARGE DATA 

COLLECTION

How was discharge data collected for SABG Table 18 (select all that apply)

□ Not applicable, data reported on form is collected at time period other than discharge→ 

Specify:

□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- 

□ admission □ discharge □ other ______ 

□ Discharge data is collected for the census of all (or almost all) clients who were admitted to 

treatment □ Discharge data is collected for a sample or all clients who were admitted to 

treatment □ Discharge records are directly collected (or in the case of early dropouts) are 

created for all (or almost all) clients who were admitted to treatment 

□ Discharge records are not collected for approximately ___ % of clients who were admitted 

for treatment 

RECORD LINKING Was the admission and discharge data linked for SABG Table 18 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using an Unique Client 

Identifier (UCID)

Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ 

Social Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as 

date of birth, gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entityspecific unique ID 

□ No, State Management Information System does not utilize UCID that allows comparison of 

admission and discharge data on a client specific basis (data developed on a cohorts basis) or 

State relied on other data sources for post admission data □ No, admission and discharge 

records were matched using probabilistic record matching.

IF DATA IS UNAVAILABLE If data is not reported, why is State unable to report (select all that apply): □ Information is not 

collected at admission □ Information is not collected at discharge □ Information is not 

collected by the categories requested □ State collects information on the indicator area but 

utilizes a different measure.

DATA PLANS IF DATA IS 

NOT AVAILABLE

State must provide time-framed plans for capturing abstinence – drug use status data on all 

clients, if data is not currently available. Plans should also discuss barriers, resource needs and 

estimates of cost.
201

SABG Table 19 – PERFORMANCE MEASURE

CHANGE IN SOCIAL SUPPORT OF RECOVERY (From Admission to Discharge) 

Most recent year for which data are available: _____________

Social Support of Recovery – Clients participating in self-help groups (e.g., AA, NA, etc.) 

(prior 30 days) at admission vs. discharge 

Admission 

Clients 

(T1)

Discharge 

Clients 

(T2)

Number of clients participating in self-help (AA NA meetings attended, etc.) [numerator] 

Total number of Admission and Discharge clients with non-missing values on self-help 

activities [denominator] 

Percent of clients participating in self-help activities 
202

State Description of Social Support of Recovery Data Collection (SABG Table 19)

STATE CONFORMANCE TO 

INTERIM STANDARD

State Description of Social Support of Recovery Data Collection (SABG Table 19):

States should detail exactly how this information is collected. Where data and methods vary from 

interim standard, variance should be described.

DATA SOURCE What is the source of data for SABG Table 19 (select all that apply):

□ Client self-report □ Client self-report confirmed by another source→ 

□ collateral source □ Administrative data source 

□ Other Specify ___________________

EPISODE OF CARE How is the admission/discharge basis defined for SABG Table 19 (Select one) □ Admission is on the 

first date of service, prior to which no service has been received for 30 days AND discharge is on the 

last date of service, subsequent to which no service has been received for 30 days 

□ Admission is on the first date of service in a Program/Service Delivery Unit and Discharge is on the 

last date of service in a Program/Service Delivery Unit

□ Other Specify ___________________________________________

DISCHARGE DATA 

COLLECTION

How was discharge data collected for SABG Table 19 (select all that apply)

□ Not applicable, data reported on form is collected at time period other than discharge→ Specify:

□ In-treatment data ___ days post-admission, OR □ Follow-up data ___ (specify) months Post- □ 

admission □ discharge □ other ______ 

□ Discharge data is collected for the census of all (or almost all) clients who were admitted to 

treatment □ Discharge data is collected for a sample or all clients who were admitted to treatment □ 

Discharge records are directly collected (or in the case of early dropouts) are created for all (or almost 

all) clients who were admitted to treatment 

□ Discharge records are not collected for approximately ___ % of clients who were admitted for 

treatment 

RECORD LINKING Was the admission and discharge data linked for SABG Table 19 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using an Unique Client Identifier 

(UCID)

Select type of UCID □ Master Client Index or Master Patient Index, centrally assigned □ Social 

Security Number (SSN) □ Unique client ID based on fixed client characteristics (such as date of birth, 

gender, partial SSN, etc.) □ Some other Statewide unique ID □ Provider-entity-specific unique ID 

□ No, State Management Information System does not utilize UCID that allows comparison of 

admission and discharge data on a client specific basis (data developed on a cohorts basis) or State 

relied on other data sources for post admission data □ No, admission and discharge records were 

matched using probabilistic record matching.

IF DATA IS UNAVAILABLE If data is not reported, why is State unable to report (select all that apply): □ Information is not 

collected at admission □ Information is not collected at discharge □ Information is not collected by 

the categories requested □ State collects information on the indicator area but utilizes a different 

measure.

DATA PLANS IF DATA IS 

NOT AVAILABLE

State must provide time-framed plans for capturing self-help participation status data on all clients, if 

data is not currently available. Plans should also discuss barriers, resource needs and estimates of 

cost.
203

SABG Table 20: RETENTION 

Length of Stay (in Days) of Clients Completing Treatment

Most recent year for which data are available: _____________

STATE:

LENGTH OF STAY

LEVEL OF CARE AVERAGE (MEAN) MEDIAN (MEDIAN) INTERQUARTILE RANGE

DETOXIFICATION (24-HOUR CARE)

1. Hospital Inpatient

2. Free-Standing Residential

REHABILITATION/ RESIDENTIAL

3. Hospital Inpatient

4. Short-term (up to 30 days)

5. Long-term (over 30 days)

AMBULATORY (OUTPATIENT)

6. Outpatient

7. Intensive Outpatient

8. Detoxification

OPIOID REPLACEMENT THERAPY

9. Opioid Replacement 

Therapy

10. ORT Outpatient
204

SABG TABLE 21– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG 

USE/ALCOHOL USE

MEASURE: 30-DAY USE

A.

Measure

B.

Question/Response

C.

Pre-populated 

Data

D.

Approved 

Substitute Data

1. 30-day 

Alcohol Use

Source Survey Item: NSDUH Questionnaire. “Think specifically about the 

past 30 days, that is, from [DATEFILL] through today. During the past 30 

days, on how many days did you drink one or more drinks of an alcoholic 

beverage?” [Response option: Write in a number between 0 and 30.]

Outcome Reported: Percent who reported having used alcohol during the past 

30 days.

Ages 12–20 - FFY 2012

Ages 21+ - FFY 2012

2. 30-day 

Cigarette Use

Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that 

is, since [DATEFILL], on how many days did you smoke part or all of a 

cigarette?” [Response option: Write in a number between 0 and 30.]

Outcome Reported: Percent who reported having smoked a cigarette during 

the past 30 days.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

3. 30-day Use of 

Other Tobacco 

Products

Source Survey Item: NSDUH Questionnaire: “During the past 30 days, that 

is, since [DATEFILL], on how many days did you use [other tobacco 

products]†

?” [Response option: Write in a number between 0 and 30.]

Outcome Reported: Percent who reported having used a tobacco product 

other than cigarettes during the past 30 days, calculated by combining 

responses to questions about individual tobacco products (snuff, chewing 

tobacco, pipe tobacco).

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

4. 30-day Use of 

Marijuana

Source Survey Item: NSDUH Questionnaire: “Think specifically about the 

past 30 days, from [DATEFILL] up to and including today. During the past 

30 days, on how many days did you use marijuana or hashish?” [Response 

option: Write in a number between 0 and 30.]

Outcome Reported: Percent who reported having used marijuana or hashish 

during the past 30 days.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

5. 30-day Use of 

Illegal Drugs 

Other Than 

Marijuana

Source Survey Item: NSDUH Questionnaire: “Think specifically about the 

past 30 days, from [DATEFILL] up to and including today. During the past 30 

days, on how many days did you use [any other illegal drug]‡

?”

Outcome Reported: Percent who reported having used illegal drugs other 

than marijuana or hashish during the past 30 days, calculated by combining 

responses to questions about individual drugs (heroin, cocaine, stimulants, 

hallucinogens, inhalants, prescription drugs used without doctors’ orders).

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

† NSDUH asks separate questions for each tobacco product. The number provided combines responses to all questions about tobacco 

products other than cigarettes.

‡ NSDUH asks separate questions for each illegal drug. The number provided combines responses to all questions about illegal drugs other 

than marijuana or hashish.
205

SABG TABLE 22– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG 

USE/ALCOHOL USE

MEASURE: PERCEPTION OF RISK/HARM OF USE

A.

Measure

B.

Question/Response

C.

Pre-populated 

Data

D.

Approved 

Substitute Data

1. Perception of 

Risk From 

Alcohol

Source Survey Item: NSDUH Questionnaire: “How much do people risk 

harming themselves physically and in other ways when they have five or more 

drinks of an alcoholic beverage once or twice a week?” [Response options: No 

risk, slight risk, moderate risk, great risk]

Outcome Reported: Percent reporting moderate or great risk.

Ages 12–20 - FFY 2012

Ages 21+ - FFY 2012

2. Perception of 

Risk From 

Cigarettes

Source Survey Item: NSDUH Questionnaire: “How much do people risk 

harming themselves physically and in other ways when they smoke one or 

more packs of cigarettes per day?” [Response options: No risk, slight risk, 

moderate risk, great risk]

Outcome Reported: Percent reporting moderate or great risk.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

3. Perception of 

Risk From 

Marijuana

Source Survey Item: NSDUH Questionnaire: “How much do people risk 

harming themselves physically and in other ways when they smoke marijuana 

once or twice a week?” [Response options: No risk, slight risk, moderate risk, 

great risk]

Outcome Reported: Percent reporting moderate or great risk.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012
206

SABG TABLE 23– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG 

USE/ALCOHOL USE

MEASURE: AGE OF FIRST USE

A.

Measure

B.

Question/Response

C.

Pre-populated 

Data

D.

Approved 

Substitute Data

1. Age at First 

Use of Alcohol

Source Survey Item: NSDUH Questionnaire: “Think about the first time you 

had a drink of an alcoholic beverage. How old were you the first time you had 

a drink of an alcoholic beverage? Please do not include any time when you 

only had a sip or two from a drink.” [Response option: Write in age at first 

use.]

Outcome Reported: Average age at first use of alcohol.

Ages 12–20 - FFY 2

Ages 21+ - FFY 2012

2. Age at First 

Use of 

Cigarettes

Source Survey Item: NSDUH Questionnaire: “How old were you the first 

time you smoked part or all of a cigarette?” [Response option: Write in age at

first use.]

Outcome Reported: Average age at first use of cigarettes.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

3. Age at First 

Use of Tobacco 

Products Other 

Than Cigarettes

Source Survey Item: NSDUH Questionnaire: “How old were you the first 

time you used [any other tobacco product]†

?” [Response option: Write in age at 

first use.]

Outcome Reported: Average age at first use of tobacco products other than 

cigarettes.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

4. Age at First 

Use of 

Marijuana or 

Hashish

Source Survey Item: NSDUH Questionnaire: “How old were you the first 

time you used marijuana or hashish?” [Response option: Write in age at first 

use.]

Outcome Reported: Average age at first use of marijuana or hashish.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

5. Age at First 

Use of Illegal 

Drugs Other 

Than Marijuana 

or Hashish

Source Survey Item: NSDUH Questionnaire: “How old were you the first 

time you used [other illegal drugs]‡?” [Response option: Write in age at first 

use.]

Outcome Reported: Average age at first use of other illegal drugs.

Ages 12–17 - FFY 2012

Ages 18+ - FFY 2012

† The question was asked about each tobacco product separately, and the youngest age at first use was taken as the measure.

‡ The question was asked about each drug in this category separately, and the youngest age at first use was taken as the measure.
207

SABG TABLE 24– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: REDUCED MORBIDITY - ABSTINENCE FROM DRUG 

USE/ALCOHOL USE

MEASURE: PERCEPTION OF DISAPPROVAL/ATTITUDES

A.

Measure

B.

Question/Response

C.

Pre-populated 

Data

D.

Approved 

Substitute Data

1. Disapproval of 

Cigarettes

Source Survey Item: NSDUH Questionnaire: “How do you feel about 

someone your age smoking one or more packs of cigarettes a day?” 

[Response options: Neither approve nor disapprove, somewhat disapprove, 

strongly disapprove]

Outcome Reported: Percent somewhat or strongly disapproving.

Ages 12–17 - FFY 2012

2. Perception of 

Peer Disapproval 

of Cigarettes

Source Survey Item: NSDUH Questionnaire: “How do you think your close 

friends would feel about you smoking one or more packs of cigarettes a 

day?” [Response options: Neither approve nor disapprove, somewhat 

disapprove, strongly disapprove]

Outcome Reported: Percent reporting that their friends would somewhat or 

strongly disapprove.

Ages 12–17 - FFY 2012

3. Disapproval of 

Using Marijuana 

Experimentally

Source Survey Item: NSDUH Questionnaire: “How do you feel about 

someone your age trying marijuana or hashish once or twice?” [Response 

options: Neither approve nor disapprove, somewhat disapprove, strongly 

disapprove]

Outcome Reported: Percent somewhat or strongly disapproving.

Ages 12–17 - FFY 2012

4. Disapproval of 

Using Marijuana 

Regularly

Source Survey Item: NSDUH Questionnaire: “How do you feel about 

someone your age using marijuana once a month or more?” [Response 

options: Neither approve nor disapprove, somewhat disapprove, strongly 

disapprove]

Outcome Reported: Percent somewhat or strongly disapproving.

Ages 12–17 - FFY 2012

5. Disapproval of 

Alcohol

Source Survey Item: NSDUH Questionnaire: “How do you feel about 

someone your age having one or two drinks of an alcoholic beverage nearly 

every day?” [Response options: Neither approve nor disapprove, somewhat 

disapprove, strongly disapprove]

Outcome Reported: Percent somewhat or strongly disapproving.

Ages 12–20 - FFY 2012
208

SABG TABLE 25– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: EMPLOYMENT/EDUCATION

MEASURE: PERCEPTION OF WORKPLACE POLICY

A.

Measure

B.

Question/Response

C.

Prepopulated 

Data

D.

Approved 

Substitute 

Data

Perception of 

Workplace 

Policy

Source Survey Item: NSDUH Questionnaire: “Would you be more or less likely to 

want to work for an employer that tests its employees for drug or alcohol use on a 

random basis? Would you say more likely, less likely, or would it make no difference 

to you?” [Response options: More likely, less likely, would make no difference]

Outcome Reported: Percent reporting that they would be more likely to work for an 

employer conducting random drug and alcohol tests.

Ages 15–17 - FFY 2012

Ages 18+ - FFY 2012

SABG TABLE 26– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: EMPLOYMENT/EDUCATION

MEASURE: AVERAGE DAILY SCHOOL ATTENDANCE RATE

A.

Measure

B.

Source

C.

Prepopulated 

Data

D.

Approved 

Substitute 

Data

Average Daily 

School 

Attendance 

Rate

Source: National Center for Education Statistics, Common Core of Data: The 

National Public Education Finance Survey available for download at 

http://nces.ed.gov/ccd/stfis.asp

Measure calculation: Average daily attendance (NCES defined) divided by total 

enrollment and multiplied by 100. 

FFY 2012

SABG TABLE 27 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: CRIME AND CRIMINAL J USTICE

MEASURE: ALCOHOL-RELATED TRAFFIC FATALITIES

A.

Measure

B.

Source

C.

Pre-populated 

Data

D.

Approved 

Substitute Data

Alcohol-Related 

Traffic Fatalities

Source: National Highway Traffic Safety Administration Fatality Analysis 

Reporting System

Measure calculation: The number of alcohol-related traffic fatalities divided 

by the total number of traffic fatalities and multiplied by 100.

FFY 2012

SABG TABLE 28– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: CRIME AND CRIMINAL J USTICE

MEASURE: ALCOHOL- AND DRUG-RELATED ARRESTS

A.

Measure

B.

Source

C.

Pre-populated 

Data

D.

Approved 

Substitute Data

Alcohol- and 

Drug-Related 

Arrests

Source: Federal Bureau of Investigation Uniform Crime Reports

Measure calculation: The number of alcohol- and drug-related arrests 

divided by the total number of arrests and multiplied by 100.

FFY 2012
209

SABG TABLE 29 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: SOCIAL CONNECTEDNESS

MEASURE: FAMILY COMMUNICATIONS AROUND DRUG AND ALCOHOL USE

A.

Measure

B.

Question/Response

C.

Pre-populated 

Data

D.

Approved 

Substitute 

Data

1. Family 

Communications 

Around Drug and 

Alcohol Use 

(Youth)

Source Survey Item: NSDUH Questionnaire: “Now think about the past 12 

months, that is, from [DATEFILL] through today. During the past 12 

months, have you talked with at least one of your parents about the dangers 

of tobacco, alcohol, or drug use? By parents, we mean either your biological 

parents, adoptive parents, stepparents, or adult guardians, whether or not 

they live with you.” [Response options: Yes, No]

Outcome Reported: Percent reporting having talked with a parent.

Ages 12–17 - FFY 2012

2. Family 

Communications 

Around Drug and 

Alcohol Use 

(Parents of children 

aged 12–17)

Source Survey Item: NSDUH Questionnaire: “During the past 12 months, 

how many times have you talked with your child about the dangers or 

problems associated with the use of tobacco, alcohol, or other drugs?”†

[Response options: 0 times, 1 to 2 times, a few times, many times]

Outcome Reported: Percent of parents reporting that they have talked to 

their child.

Ages 18+ - FFY 2012

† NSDUH does not ask this question of all sampled parents. It is a validation question posed to parents of 12- to 17-year-old survey 

respondents. Therefore, the responses are not representative of the population of parents in a State. The sample sizes are often too small 

for valid reporting.

SABG TABLE 30 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: RETENTION

MEASURE: PERCENTAGE OF YOUTH SEEING, READING, WATCHING, OR LISTENING TO A PREVENTION MESSAGE

Measure Question/Response Pre-populated 

Data

Approved 

Substitute Data

Exposure to 

Prevention 

Messages

Source Survey Item: NSDUH Questionnaire: “During the past 12 months, do 

you recall [hearing, reading, or watching an advertisement about the 

prevention of substance use]†

?” 

Outcome Reported: Percent reporting having been exposed to prevention 

message.

Ages 12–17 - FFY 2012

† This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within a 

specific context
210

SABG Tables 31-35 – Reporting Period

Reporting Period - Start and End Dates for Information Reported on SABG Tables 31, 32, 33, 34, and 35.

Instructions for completing reporting Start and End Dates

The following chart is for collecting information on the reporting periods for the data entered in SABG Tables 31, 32, 33, 34 and 35.

See: The instructions for and the data entered in SABG Tables 31, 32, 33, 34 and 35.

Rows 1 through 5 each correspond to a single form in the current year’s application among the following five tables: 31, 32, 33, 34 and 

35.

Column A – Enter the reporting period start date. 

Column B – Enter the reporting period end date. 

The date format to be entered in columns A and B should be month/day/year, as follows.

• Month: enter 2 digits (e.g. January = 01; December = 12)

• Day: enter 2 digits (e.g. 1st of the month = 01; 15th of the month =15)

• Year: enter all 4 digits (e.g., 2009)

Reporting Period Start and End Dates for Information Reported on SABG Tables 31, 32, 33, 34 and 35

Please indicate the reporting period (start date and end date totaling 12 months by the State)

for each of the following fNOMS. The start date and end date for NOMS 31-35 should be the same..

Tables A. Reporting Period 

Start Date

B. Reporting Period 

End Date

1. SABG Table 31 

Individual-Based Programs and Strategies –

Number of Persons Served by Age, Gender, 

Race, and Ethnicity

mm/dd/yyyy mm/dd/yyyy

2. SABG Table 32

Population-Based Programs and Strategies 

– Number of Persons Served by Age, 

Gender, Race, and Ethnicity

mm/dd/yyyy mm/dd/yyyy

3. SABG Table 33 (Optional) 

Number of Persons Served by Type of 

Intervention

mm/dd/yyyy mm/dd/yyyy

4. SABG Table 34

Number of Evidence-Based Programs and 

Strategies by Type of Intervention

mm/dd/yyyy mm/dd/yyyy

5. SABG Table 35

Total Number of Evidence-Based Programs 

and Total SAPT BG Dollars Spent on 

Evidence-Based Programs/Strategies

Data s ubmitted on SABG 

Table 35 must correspond 

to the reporting period 

start date us ed for SABG 

Table 34

Data s ubmitted on SABG 

Table 35 must correspond 

to the reporting period end 

date us ed for SABG Table

34
211

General Questions Regarding Prevention NOMS Reporting

Question 1: Describe the data collection system you used to collect the NOMs data (e.g., MDS, DbB, KIT Solutions, manual process).

Question 2: Describe how your State’s data collection and reporting processes record a participant’s race, specifically for participants 

who are more than one race.

Indicate whether the State added those participants to the number for each applicable racial category or whether the State added all those 

participants to the More Than One Race subcategory.

SABG Table 31 – SUBSTANCE ABUSE PREVENTION Individual-Based Programs and Strategies—Number of 

Persons Served by Age, Gender, Race, and Ethnicity

Category Total

A. Age

0–4

5–11

12–14

15–17

18–20

21–24

25–44

45–64

65 and Over

Age Not Known

B. Gender

Male

Female

Gender Not Known

C. Race

White

Black or African American

Native Hawaiian/Other Pacific Islander

Asian

American Indian/Alaska Native

More Than One Race (not OMB required)

Race Not Known or Other (not OMB required)

D. Ethnicity

Hispanic or Latino 

Not Hispanic or Latino
212

SABG Table 32 – SUBSTANCE ABUSE PREVENTION Population-Based Programs and Strategies—Number of 

Persons Served by Age, Gender, Race, and Ethnicity

Category Total

A. Age

0–4

5–11

12–14

15–17

18–20

21–24

25–44

45–64

65 and Over

Age Not Known

B. Gender

Male

Female

Gender Not Known

C. Race

White

Black or African American

Native Hawaiian/Other Pacific Islander

Asian

American Indian/Alaska Native

More Than One Race (not OMB required)

Race Not Known or Other (not OMB required)

D. Ethnicity

Hispanic or Latino 

Not Hispanic or Latino
213

SABG Table 33 (Optional) – SUBSTANCE ABUSE PREVENTION Number of Persons Served by Type of Intervention

Intervention Type

Number of Persons Served by Individual- or Population-Based Program or 

Strategy

A.

Individual-Based

Programs and Strategies

B.

Population-Based Programs and 

Strategies

1. Universal Direct N/A

2. Universal Indirect N/A

3. Selective N/A

4. Indicated N/A

5. Total
214

 SABG Table 34 – SUBSTANCE ABUSE PREVENTION Evidence-Based Programs and Strategies by Type of Intervention

1. Describe the process the State will use to implement the guidelines included in the above definition.

2. Describe how the State collected data on the number of programs and strategies. What is the source of the data?

SABG Table 34– SUBSTANCE ABUSE PREVENTION Number of Evidence-Based Programs and Strategies by Type of Intervention

Number of Programs and Strategies by Type of Intervention

A.

Universal

Direct

B.

Universal

Indirect

C.

Universal

Total

D.

Selective

E.

Indicated

F.

Total

1. Number of Evidence-Based 

Programs and Strategies Funded

2. Total number of Programs and 

Strategies Funded

3. Percent of Evidence-Based 

Programs and Strategies
215

SABG Table 35 – Total SUBSTANCE ABUSE PREVENTION Number of Evidence Based Programs and Total SAPT BG Dollars 

Spent on SUBSTANCE ABUSE PREVENTION Evidence-Based Programs/Strategies

Total Number of Evidence-Based Programs/Strategies for 

IOM Category below:

Total SAPT Block Grant $Dollars Spent on evidence-based 

Programs/Strategies 

Universal Direct Total # $

Universal Indirect Total # $

Selective Total # $

Indicated Total # $

Total EBPs: Total Dollars Spent: $
216

Prevention Attachments A and B – Completing the State request for data substitution application and the State substitution 

appeal forms (below): 

These forms should be completed if a State wishes to substitute data collected through a State effort for the prevention prepopulated National Outcome Measures (NOMs) on the NOMs Data Collection and Reporting Forms. If the State is requesting 

substitutions for more than one NOM, one application should be completed for all NOMs for which a substitution is requested. 

A state may also appeal a decision that the State will not be allowed to substitute pre-populated with the States data.

Prevention Attachment A:

Application Form to Substitute Data

1. CONTACT INFORMATION

State/Territory/tribe:

Name of the applicant (first and last name):

Title:

 Mr.  Ms.  Dr.  Other _____________________

State position:

Organization:

Department:

Mailing address:

E-mail address:

Telephone:

Fax:

2. MEASURE LABELS

Label of the National Outcome Measure (NOM) being replaced:

Label of the substituted measure (if not identical to the NOM):

3. Narrative Justification

Provide a brief description of the reasons for the substitution. Continue on the back of the page if necessary.

4. Data Source for Substituted Measure

Name of the agency or organization responsible for data collection:

Name of contact person at data collection agency/organization (first and last name):
217

E-mail address:

Telephone:

Most recent year for which data are available:

Is data collection repeated every year?

 Yes  No (Indicate frequency of data collection.)______________________

Are trend data available?

 Yes (Indicate start year of trend data.)_________________________  No 

What is the mode of data collection?  Census  Survey (Please complete item 5.)

 Other (Please describe.)

5. SURVEY DESCRIPTION

(Skip if mode of data collection is not a survey.)

The following questions refer to the most recent implementation of the survey.

Date of data collection:

Sample size:

Sampling ratio (sample size divided by the size of the target population):

What type of sampling strategy was used to select respondents? (Please check one.)

 Convenience sample (no statistical sampling techniques were used)

 Probability sample (statistical sampling techniques were used)

The following four questions apply to probability samples only.

If the sample is stratified, please identify each stratum:

If cluster sampling was used, please identify the clustering unit(s):

If a multistage design was used, please identify the unit sampled at each stage:

Potential sources of bias in the sample design:

The following questions apply to all surveys.

Method of administration:  Mail-in  Telephone  Face-to-face

 School-based: self-administered  Self-administered: survey site other than a school

 Other (Please specify.)

Was the interview computer-assisted?  Yes  No
218

Name of the survey instrument:

What was the survey response rate (i.e., multiply the number who took the survey/original sample size by 100)?

Were there validity and reliability tests of the survey items constituting the substitute measure?

 No

 Yes (Please describe reliability/validity study/studies.)

Are there any published validity/reliability studies for this instrument?

 No

 Yes (Please provide bibliographic information.)

6. DATASET SUBMISSION INFORMATION

Name of the data file(s) being submitted:

Description of data file(s) (Include format and size.):

For each data file, describe the content of the data records (e.g., “Each record contains all of the information for a single individual.”):

Names of documentation files:

Description of documentation file(s):

Total number of files being submitted:
219

Prevention Attachment B:

Substitution Appeal Form

State/Territory/tribe:

Date substitution application submitted:

Date denial received:

Date appeal submitted:

1. CONTACT INFORMATION

Name of the applicant (first and last name):

 Mr.  Ms.  Dr.  Other _____________________

Organization:

Department:

Mailing address:

E-mail address:

TELEPHONE:

FAX:

2. MEASURE(S) BEING APPEALED

National Outcome Measure(s) (NOM) being appealed:

Summarize SAMHSA’s reason(s) for the denial of the substitution:

3. RATIONALE FOR THE APPEAL

State the rationale for appealing SAMHSA’s decision:

4. ATTACH A COPY OF THE ORIGINAL SUBSTITUTION APPLICATION.

5. ADDITIONAL DATA OR ANALYSIS TO SUPPORT THE APPEAL.

Describe any additional data or analysis that supports the appeal: 
220

PREVENTION ATTACHMENT C:

APPROVED SUBSTITUTE DATA SUBMISSION FORM

Create a separate form for each data source.

GRANTEE AND CONTACT INFORMATION

State/Territory/tribe:

Name of contact person (first and last name):

 Mr.  Ms.  Dr.  Other _____________________

Organization:

Department:

Mailing address:

E-mail address:

TELEPHONE: FAX:

DATE

Enter the date when the Application Form To Substitute Data was submitted:

If final approval was obtained after an appeal process, enter the date when the appeal was filed:

Enter the date when approval to submit alternative data was obtained:

MEASURE(S)

Enter the NOMs measure(s) for which State-generated data are being substituted:__________
221

SABG Table 36: (Optional Worksheet) Program/Strategy Detail for Computing the Total Number of Evidence-based 

Programs and Strategies, and for Reporting Total SAPT Block Grant Funds Spent on substance abuse prevention EvidenceBased Programs and Strategies.

1 2 3 4

Program/Strategy Name

Universal Direct

Total Number of 

Evidence-based Programs 

and Strategies by 

Intervention

Total Costs of 

Evidence 

 based Programs and 

Strategies for 

each IOM 

Category 

Total SAPT Block Grant Funds Spent 

on Evidence-Based 

Programs/Strategies

1.

2.

3.

4.

Subtotal

Universal Indirect 

Programs and 

Strategies

1.

2.

3.

4.

Subtotal

Selective Programs and 

Strategies

1.

2.

3.

4.

Subtotal

Indicated Programs and 

Strategies

1.

2.

3.

4.

Subtotal

Total Number of 

(EBPs)/Strategies and 

cost of these 

EBPs/Strategies

# $

Total SAPT Block Grant 

substance abuse 

prevention Dollars $ 

Spent on EvidenceBased Programs and 

Strategies 

$