1

Block Grant Reporting Section 

FY 2016

FY 2017

CFDA 93.959 

(Substance Abuse Prevention and Treatment)

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration
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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
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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
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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 Only and MH/SA BG Applications

FY for which the state

is applying for funds

Application

Due

Plan

Due

Planning Period SABG Report 

Due

Synar Report

Due

2016 9/1/2015 Yes 7/1/15 – 6/30/17 12/1/2015

Compliance 

Year is 2013

12/31/2015

2017 9/1/2016 No* NA 12/1/2016

Compliance 

Year is 2014

1/3/2017

*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 2016 and 2017. 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. 
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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.
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B. Annual Update 

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

2016/2017 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 2016/2017 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:

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

b) First-year target/outcome measurement (Progress – end of SFY 2016):

c) Second-year target/outcome measurement (Final – end of SFY 2017):

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:
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C. State Agency Expenditure Reports

States and Jurisdictions are required 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 (requested) 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 (requested) 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 
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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.
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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 (Other than 

Primary 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*

7. Administration (excluding program / 

provider level administration)

8. Total

*Only HIV designated states should enter information in this row.
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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.

Service

SABG

Expenditures

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 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)

Systematic Planning/Coalition and Community Team Building (Community- Based Process)

Parenting and family management (Education)

Education programs for youth groups (Education)

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 $ $
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Service

SABG

Expenditures

MHBG 

Expenditures

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

Recovery Supports 

$$

Peer Support

Recovery Support Coaching

Recovery Support Center Services

Supports for Self-directed Care

Other Supports (Habilitative)

$$

Personal Care

Homemaker

Respite
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Service

SABG

Expenditures

MHBG 

Expenditures

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 Mental Health Residential 

Youth Substance Abuse Residential Services

Children's Residential Mental Health Services 

Therapeutic Foster Care

Acute Intensive Services

$$

Mobile Crisis

Peer-based Crisis Services

Urgent Care

23-hour Observation Bed

Medically Monitored Intensive Inpatient (SA) 

24/7 Crisis Hotline Services

Other (please list)

$$

Total

$$
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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. For detailed instructions, 

refer to those in BGAS. Only one column is to be filled in each year.

State Agency SABG Expenditure Compliance Report

SABG Table 4 FY 2013 SA Block Grant Award FY 2014 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

** For HIV Designated States only
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SABG Table 5a - Primary Prevention Expenditures Checklist

The State or Jurisdiction must complete either SABG Table 5a and/or 5b. 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, such as the development of the sample design and the conducting of 

the inspections. States should include an non-SABG funds that were allotted 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 $ $ $ $ $
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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.)
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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 2014 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

% %
17

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 2014 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
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SABG Table 6 - SABG Resource Development Expenditures Checklist

If the State or Jurisdiction funded resource development activities with a SABG award, it is required to complete this table for the obligation and 

expenditure period of the award. 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

 
OMB No. 0930-0080

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

A B B D E

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

$ $ $ $ $

$ $ $ $ $

Total $ $ $ $ $
OMB No. 0930-0080

Description of Calculations for MOE Tables 8a through 8d 

Please provide a description of the amounts and methods used to calculate the following: 

(a) total Single State Agency (SSA) expenditures for substance abuse prevention and treatment 42 U.S.C. §300x-30;

(b) the base and Maintenance of Effort (MOE) for tuberculosis services as required by 42 U.S.C. §300x-24(d);

(c) (for designated states only) the base and MOE for HIV early intervention services as required by 42 U.S.C.§300x-24(d) 

(See 45 C.F.R. §96 122(f)(5)(ii)(A)(B)(C)); and

(d) the base and, for 1994 and subsequent fiscal years, report the Federal and State expenditures for such services for services 

to pregnant women and women with dependent children as required by 42 U.S.C. §300x-22(b)(1).
OMB No. 0930-0080

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. (Dates given are for the 2017 SABG Report. For the 2018 SABG report, increase each year by one.)

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 (2014) + B2 (2015)

2

(C)

SFY 2014

(1)

SFY 2015

(2)

SFY 2016

(3)

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

Yes No

SFY 2014

SFY 2015

SFY 2016

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? ___/___/_____
OMB No. 0930-0080

 mm/dd/yyyy

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 2016* (3)

*Date given is for the 2017 SABG Report. For the 2018 SABG Report, increase the year by one.)
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 2016*

 *Date given is for the 2017 SABG Report. For the 2018 SABG Report, increase the year by one.)
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 specialized treatment and related services which 

meet the SABG requirements for pregnant women and women with dependent children during the State fiscal year immediately preceding the federal 

fiscal year for which the state is applying for funds. (Dates given are for the 2017 SABG Report. For the 2018 SABG Report, increase each year 

(other than the base year) by one.

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

2014

2015

2016
25

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. ORT Detoxification $ $ $

10. Opioid Replacement Therapy
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/Alaska

n 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.
31

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.
 32

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. 
 33

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.

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.
 34

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 part-time) (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) 
35

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.
36

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 
DO NOT DISTRIBUTE – CLOSE HOLD

SAPT BG APPLICATION 37

State Description of Stability in Housing Data Collection (SABG Table 15)

STATE 

CONFORMANCE TO 

INTERIM STANDARD

State Description of Criminal Involvement 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 SABG 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-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.
38

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 
 

39

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.
40

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)
41

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.
42

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)
43

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.
44

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 
45

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.
46

SABG Table 20: RETENTION 

Length of Stay (in Days) of Clients Completing Treatment

Most recent year for which data are available: _____________

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. ORT Detox

10. Opioid Replacement 

Therapy
Approval Expires 09-30-2010

47

Section V: Performance Indicators and Accomplishments 

Tables 21-36: Prevention Performance Measures

Tables 21 – 30 Prevention Performance Measures 

Introduction 

The National Outcome Measures (NOMs) are a set of domains and measures that the Substance 

Abuse and Mental Health Services Administration (SAMHSA) uses to accomplish its vision and 

to meet all of its Federal reporting requirements, thus reducing burden and redundancy for 

grantees. 

The NOMs Data Collection and Reporting tables are to be completed as part of the state's annual 

SABG application. For Tables 21-25 and 27-30, the compliance year is calendar year (CY) 2014 

(note that pre-populated NOMs from the National Survey on Drug Use and Health (NSDUH) 

reflect pooled data from CYs 2013-2014. For substance abuse prevention NOMs Table 26, the 

compliance year is School Year 2014.

For purposes of this section, unless otherwise noted, the term "state" refers to states, territories, 

and the one Native American tribe that receive SABG funding. 

Tables 21 through 30 Information 

A. Pre-populated Data 

CSAP and the states have agreed that the state-level reporting requirement for the NOMs listed 

in Tables 21-30 will be fulfilled through the use of extant data from sources including the 

National Survey on Drug Use and Health (NSDUH), the Fatality Analysis Reporting System 

(FARS) of the National Highway Traffic Safety Administration, the Uniform Crime Report 

(UCR) of the Federal Bureau of Investigation, and the National Center for Education Statistics 

(NCES) of the U.S. Department of Education. These pre-populated state-level NOMs will meet 

most of the state-level NOMs reporting requirements for the prevention portion of the SABG 

funding. These data will be pre-populated into the data tables by CSAP. 

NOMs Domain - Reduced Morbidity Abstinence from Drug Use/Alcohol Use 

• Table 21: 30-Day Use 

• Table 22: Perception of Risk/Harm of Use 

• Table 23: Age of First Use 

• Table 24: Perception of Disapproval/Attitudes 

NOMs Domain - Employment/Education 

• Table 25: Perception of Workplace Policy 

• Table 26: Average Daily School Attendance Rate

NOMs Domain - Crime and Criminal Justice 

• Table 27: Alcohol-Related Traffic Fatalities 

• Table 28: Alcohol- and Drug-Related Arrests

NOMs Domain - Social Connectedness 
Approval Expires 09-30-2010

48

• Table 29: Family Communications Around Drug and Alcohol Use

NOMs Domain - Retention 

• Table 30: Youth Seeing, Reading, Watching, or Listening to a Prevention Message 

In this block grant application, pre-populated data are automatically provided to fulfill the 

majority of the reporting requirements. 

Territories and Native American tribes for which there are no NSDUH, FARS, UCR, and/or 

NCES data will not be required to report on those measures at the state level, but will be 

encouraged to provide substitute data. 

B. Supplemental Data 

States may also wish to provide additional data related to the NOMs. The data can be included in 

the block grant appendix. When describing the supplemental data, states should provide any 

relevant Web addresses (URLs) that provide links to specific state data sources. 

D. Instructions for Completing Forms 

Column A: Measure - The SAMSHA-defined measure for the domain listed. 

Column B: Question/Response 

• Source Survey Item: For Table 21-25, 29, and 30, the source is the NSDUH. For Tables 26-28 

other "archival" sources are identified. The specific language used for each item is provided. 

• Response Option: The range of responses that are provided for the survey item. 

• Outcome Reported: The specific responses that are included in the calculation provided for the 

item. 

• Age: The age range for which the responses are provided. 

Column C: Pre-populated Data - Pre-populated data are provided; see description below. 

Column D: Supplemental Data, if any
49

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.

Prepopulated 

Data

D.

Supplemental 

Data, if any

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 – CY 2013-2014

Ages 21+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

† 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.
50

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.

Prepopulated 

Data

D.

Supplemental

Data, if any

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 - CY 2013-2014

Ages 21+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014
51

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.

Prepopulated 

Data

D.

Supplemental

Data, if any

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 - CY 2013-2014

Ages 21+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

†

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.
52

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.

Prepopulated 

Data

D.

Supplemental

Data, if any

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 - CY 2013-2014

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 - CY 2013-2014

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 - CY 2013-2014

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 - CY 2013-2014

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 - CY 2013-2014
53

SABG TABLE 25– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: EMPLOYMENT/EDUCATION

MEASURE: PERCEPTION OF WORKPLACE POLICY

A.

Measure

B.

Question/Response

C.

Prepopulated 

Data

D.

Supplemen

tal Data, if 

any

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 - CY 2013-2014

Ages 18+ - CY 2013-2014

SABG TABLE 26– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: EMPLOYMENT/EDUCATION

MEASURE: AVERAGE DAILY SCHOOL ATTENDANCE RATE

A.

Measure

B.

Source

C.

Prepopulated 

Data

D.

Supplemen

tal Data, if 

any

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. 

CY 2014

SABG TABLE 27 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: CRIME AND CRIMINAL JUSTICE

MEASURE: ALCOHOL-RELATED TRAFFIC FATALITIES

A.

Measure

B.

Source

C.

Prepopulated 

Data

D.

Supplemental 

Data, if any

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.

CY 2014

SABG TABLE 28– SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: CRIME AND CRIMINAL JUSTICE

MEASURE: ALCOHOL- AND DRUG-RELATED ARRESTS

A.

Measure

B.

Source

C.

Prepopulated 

Data

D.

Supplemental 

Data, if any

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.

CY 2014
54

SABG TABLE 29 – SUBSTANCE ABUSE PREVENTION NOMS DOMAIN: SOCIAL CONNECTEDNESS

MEASURE: FAMILY COMMUNICATIONS AROUND DRUG AND ALCOHOL USE

A.

Measure

B.

Question/Response

C.

Prepopulated 

Data

D.

Supplemental 

Data, if any

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 - CY 2013-2014

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+ - CY 2013-2014

† 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 Prepopulated 

Data

Supplemental 

Data, if any

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 - CY 2013-2014

† This is a summary of four separate NSDUH questions each asking about a specific type of prevention message delivered within a

specific context
55

SABG Tables 31-35 – Reporting Period

Reporting Period - Start and End Dates for Information Reported on SABG Tables 31, 32, 33, 34, 

and 35.

The following chart is for collecting information on the reporting periods for the data entered in 

Tables 31-35. Please note that the correct reporting period for Tables 31-34 is the Calendar 

Year (CY) which coincides with the reporting period for the pre-populated prevention 

NOMs in Tables 21-30. We understand that some states have reported on the State Fiscal 

Year (SFY) or Federal Fiscal Year (FFY) for these tables in past SABG Reports. If your 

state is unable to report on the calendar year, please indicate in this footnote why you are 

unable to report on the calendar year and the steps the state intends to take to make 

calendar year reporting possible in future years. Note that the correct reporting period for 

Table 35 is the SABG compliance period that coincides with the reporting period for 

Tables 4, 5a, 5b, 6 and 7.

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. 2012, 2013) 

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 NOMS. 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 EvidenceBased Programs/Strategies

mm/dd/yyyy mm/dd/yyyy
56

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. Ethnicity

Hispanic or Latino 

Not Hispanic or Latino

Ethnicity Unknown

D. Race

White

Black or African American

Native Hawaiian/Other Pacific Islander

Asian

American Indian/Alaska Native
Form P12a DO NOT DISTRIBUTE – CLOSE HOLD

57

More Than One Race (not OMB required)

Race Not Known or Other (not OMB required)
58

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

Ethnicity unknown
59

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

2. Universal Indirect

3. Selective

4. Indicated

5. Total
60

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
61

SABG Table 35 – Total SUBSTANCE ABUSE PREVENTION Number of Evidence Based 

Programs/Strategies 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: $
62

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 Evidence-Based 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 

$