Block Grant Reporting Section 

CFDA 93.959 

Substance Use Prevention, Treatment, and Recovery Services 

Block Grant 

(SUPTRS BG) 

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 

 

 

 

Table of Contents 

A. Introduction 

B. Annual Update 

SUPTRS BG Table 1 Priority Area and Annual Performance Indicators – Progress Report 

C. State Agency Expenditure Reports 

SUPTRS BG Table 2 - State Agency Expenditure Report 

SUPTRS BG Table 3a - Syringe Services Program 

SUPTRS BG Table 3b - Expenditures for Syringe Services Programs (SSPs) Program Information 

SUPTRS BG Table 3c – Harm Reduction Activities 

SUPTRS BG Table 4 - SUPTRS BG State Agency Expenditure Compliance Report 

SUPTRS BG Table 5a - SUPTRS BG Primary Prevention Expenditures 

SUPTRS BG Table 5b - SUPTRS BG Primary Prevention Targeted Priorities 

SUPTRS BG Table 6 - Systems Development/Non-Direct Service Activities Expenditure 

SUPTRS BG Table 7 - SUPTRS BG Statewide Entity Inventory 

SUPTRS BG Table 8a - Maintenance of Effort for State Expenditures for Substance Use Disorder Prevention, Treatment, and 

Recovery 

SUPTRS BG Table 8b - Base and Maintenance of Effort for Expenditures for Services to Pregnant Women and Women with 

Dependent Children 

D. Population and Services Reports 

SUPTRS BG Table 9 - Prevention Strategy Report 

SUPTRS BG Table 10a - Treatment Utilization Matrix 

SUPTRS BG Table 10b – Number of Persons Served (Unduplicated Count) Who Received Recovery Supports 

SUPTRS BG Table 11a - Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use 
 

 

 

SUPTRS BG Table 11b - COVID-19 Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use 

SUPTRS BG Table 11c - Sexual Orientation and Number of Persons Served (Unduplicated Count) for Alcohol and Other Drug Use 

SUPTRS BG Table 12 - SUPTRS BG HIV Early Intervention Services in Designated States 

SUPTRS BG Table 13 - Charitable Choice 

E. Performance Data and Outcomes 

Treatment Performance Measures 

SUPTRS BG Table 14 - Employment/Education Status 

SUPTRS BG Table 15 - Stability of Housing 

SUPTRS BG Table 16 - Criminal Justice Involvement 

SUPTRS BG Table 17 - Change in Abstinence–Alcohol Use 

SUPTRS BG Table 18 - Change in Abstinence – Other Drug Use 

SUPTRS BG Table 19 - Change in Social Support of Recovery 

SUPTRS BG Table 20 - Retention 

Prevention Performance Measures 

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

SUPTRS BG Table 22 - Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure: Perception of Risk/Harm of Use 

SUPTRS BG Table 23 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Age of First Use 

SUPTRS BG Table 24 - Reduced Morbidity–Abstinence from Drug Use/Alcohol Use; Measure: Perception of Disapproval/Attitudes 

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

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

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

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

SUPTRS BG Table 29 - Social Connectedness; Measure: Family Communications around Drug and Alcohol Use 

SUPTRS BG Table 30 - Retention; Measure: Percentage of Youth Seeing, Reading, Watching, or Listening to a Prevention Message 

SUPTRS BG Table 31-35 – Reporting Period – Start and End Dates for Information Reported on Tables 31, 32, 33, 34, and 35 
 

 

 

 

 

SUPTRS BG Table 31 - Individual-Based Programs and Strategies; Measure: Number of Persons Served by Age, Gender, Race, and 

Ethnicity 

SUPTRS BG Table 32 - Population-Based Programs and Strategies; Measure: Number of Persons Served by Age, Gender, Race, and 

Ethnicity 

SUPTRS BG Table 33 - Number of Persons Served by Type of Intervention 

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

SUPTRS BG Table 35 - Number of Evidence-based Programs and Strategies, and Total SUPTRS BG Funds Spent on Evidence Based 

Programs/ Strategies. 

Section A. Introduction 

Section 1942(a) of Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. § 300x-52(a)) requires the Secretary of the U.S. 

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 states1 have implemented the State Plan for the preceding fiscal year. The 

purpose of the Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUPTRS BG) (formerly known as Substance 

Abuse Prevention and Treatment Block Grant (SABG)) Annual Report is to provide information to assist the Secretary in making this 

determination. 

States 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 (FFY) for which the state is applying for funds; and (2) the obligation and expenditure period of the SUPTRS 

BG Notice of Award (NoA) subject to the Center for Substance Abuse Treatment (CSAT) compliance review (Compliance Award), in the 

format provided in this guidance. The SUPTRS BG Annual Report will address the purposes for which the SUPTRS BG funds were 

expended, identify the sub-recipients which received SUPTRS BG funds, and the authorized activities and services grantees 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. 

1 The term “state” means each of the several states, the District of Columbia and each of the territories of the United States. The term “territories of the United States” 

means each of the Commonwealth of Puerto Rico, Virgin Islands, American Samoa, Commonwealth of the Northern Marianas Islands, Federated States of Micronesia, 

Guam, Republic of the Marshall Islands, and the Republic of Palau. 
 

 

 

All states are required to prepare and submit their respective SUPTRS BG Annual Reports utilizing SAMHSA’s Web Block Grant 

Application System (WebBGAS). Annual reports must be received by SAMHSA not later than December 1st for a state or jurisdiction to 

receive its fiscal year SUPTRS BG NoA. If a due date falls on a weekend or federal holiday, the receipt date for a report will be the next 

business day. The following schedule provides specific due dates for the SUPTRS BG and MHBG/SUPTRS BG Applications, SUPTRS BG 

Annual Reports, MHBG Implementation Reports, and the Annual Synar Reports: 

Due Dates for SUPTRS BG Only and MHBG/SUPTRS BG Applications 

FFY for which the state 

is applying for funds 

Application 

Due 

Plan 

Due 

Planning Period SUPTRS BG 

Report 

Due 

Synar Report 

Due 

2024 9/1/2023 Yes 7/1/ 23– 6/30/25 12/1/2023 

Compliance 

Year is 2021 

12/31/2023 

2025 9/1/2024 No N/A 12/1/2024 

Compliance 

Year is 2022 

12/31/2024 

Due Dates for Reports 

Applicable FFY SUPTRS BG Annual Report MHBG Implementation Report Annual Synar Report 

2024 12/01/ 2023 12/01/2023 12/31/2023 

2025 12/01/2024 12/01/2024 12/31/2024 

States are required to prepare and submit an annual report comprised of the following sections: 

Section B: Annual Update - In this section, states are required to provide a brief review of the extent to which their respective plans were 

implemented and met priorities and goals identified in the SUPTRS BG plan covering SFY 2024 and 2025. The report should also include a 

brief review of areas that the state identified in the SUPTRS BG plan as needing improvement and changes that the state or jurisdiction 

proposes to make to achieve the goals established. 
 

 

Section C: State Agency Expenditure Reports - In this section, states must provide information regarding expenditures for authorized 

activities and services for primary substance use disorder (SUD)2

 prevention, treatment, and recovery. The state must provide a description of 

SUPTRS BG expenditures, supplemental expenditures authorized under the Coronavirus Response and Relief Supplement Appropriations 

Act, COVID-19, 2021 [P.L. 116-260], and the American Rescue Plan Act (ARP), 2021 [P.L. 117-2], as well as expenditures for authorized 

activities to prevent substance misuse and treat SUDs and related tuberculosis (TB) services. 

Section D: Populations and Services Reports - In this section, states must provide specific information regarding the number of individuals 

served with SUPTRS BG. In addition, states should provide specific information regarding the services these individuals received. 

Section E: Performance Indicators and Accomplishments - In this section of the report, states 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 use disorder prevention, SUD treatment, and recovery. 

B. Annual Update 

The information that states enter in SUPTRS BG Table 1 in the planning section of the 2024/2025 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 2024/2025 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, along with remedial steps proposed 

to meet the target. 

2 The term “substance use disorder” means substance-related and addictive disorders as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth 

Edition, Arlington, VA, American Psychiatric Association, 2013. 
SUPTRS BG Table 1 - Priority Areas and Annual Performance Indicators – Progress Report 

Priority Areas and Annual Performance Indicators 

1. Priority Area: 

2. Priority Type (SAP, SAT, MHS): 

3. Population(s) (SMI, SED, FEP, PWWDC, PP, PWID (formerly IVDUs), EIS/HIV, 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 2024): 

c) Second-year target/outcome measurement (Final – end of SFY 2025): 

d) Data source: 

e) Description of data: 

f) Data issues/caveats that affect outcome measures: 

Priority Areas and Annual Performance Indicators (continued) 

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: 
 

 

 

 

 

 

 

 

 

 

 

 

C. State Agency Expenditure Reports 

States are required to provide information regarding SUPTRS BG, state funds, and other supplemental funds (i.e., COVID-19, ARP) 

expended for authorized activities to prevent and treat SUDs and for related public health services, e.g., TB and, if applicable, early 

intervention services regarding the human immunodeficiency virus (EIS/HIV). Please complete the tables described below: 

SUPTRS BG Table 2 - State Agency Expenditure Report. This table provides a report of SUPTRS BG, and state expenditures by the 

principal agency of a state, i.e., single state agency (SSA), during the SFY immediately preceding the FFY for which the state is applying 

for funds. Expenditures to be reported are for authorized activities to prevent and treat SUDs pursuant to section 1921 of Title XIX, Part 

B, Subpart II of the Public Health Service (PHS) Act (42 U.S.C. § 300x-21); TB services; EIS/HIV, if applicable; pursuant to section 

1924(b) of Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. § 300x-24(b)); and administration pursuant to section 1931(a)(2) of 

Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. § 300x-31(a)(2)). Activities should also include expenditures related to recovery 

support services as mandated by the Consolidated Appropriations Act, 2023. In column A, the applicable FFYs’ SUPTRS BG funds 

expended during the SFY should be included. In column I, applicable FFYs ARP Supplement funds expended during the SFY should be 

included. NOTE: In column H, include applicable FFYs COVID-19 expenditures per SAMHSA guidance. Grantees may be requested to 

report on MHGB and SUPTRS BG COVID-19 Supplemental Funding expenditures in WebBGAS in accordance with requirements 

included in their current NoA Terms and Conditions. 

SUPTRS BG Table 3a - Syringe Services Program. This table provides a report of SUPTRS BG and supplemental expenditures per 

SAMHSA guidance for elements of syringe services programs (SSP) carried out by SUPTRS BG sub-recipients as described in the 

guidance disseminated by the Office of HIV/AIDS and Infectious Disease Policy, the Centers for Disease Control and Prevention, 

National Center on HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of HIV Prevention, and SAMHSA. The authorization 

to expend federal funds for elements of a syringe services program is subject to an authorization in the annual appropriations’ bill(s). 

NOTE: For FFY 2024 this table provides a report of expenditures from the ARP Supplement funding as well as COVID-19 Relief 

Supplement in accordance with requirements included in grantees’ current NoA Terms and Conditions. 

SUPTRS BG Table 3b - Expenditures for SSPs Program Information. This table is intended to capture the unduplicated count of persons 

that received onsite services from an SSP or were referred to services by an SSP including HIV, Hepatitis C, and sexually transmitted 

disease (STI) testing, treatment for substance use disorders, and treatment for physical health conditions. NOTE: For FFY 2024 this table 

provides a report of expenditures from the ARP Supplement funding as well as COVID-19 Relief Supplement in accordance with 

requirements included in grantees’ current NoA Terms and Conditions. 
 

 

 

 

 

 

 

 

 

 

SUPTRS BG Table 3c – Harm Reduction Activities. This table is intended to capture the extent to which SUPTRS BG funds (other than 

primary prevention) are used to support grantee’s harm reduction activities, specifically naloxone kit purchase and distribution as well as 

the purchase and distribution of fentanyl test strips. NOTE: For FFY 2024 this table provides a report of expenditures from the ARP 

Supplement funding as well as COVID-19 Relief Supplement in accordance with requirements included in grantees’ current NoA Terms 

and Conditions. 

SUPTRS BG Table 4 - SUPTRS BG State Agency Expenditure Compliance Report. This table provides a report of expenditures for 

authorized activities to prevent and treat SUDs associated with a SUPTRS BG NoA for the applicable fiscal year. It covers the twoyear obligation and expenditure period. 

SUPTRS BG Table 5a - SUPTRS BG Primary Prevention Expenditures. This table provides a report of primary prevention expenditures 

associated with a SUPTRS BG NoA for the applicable fiscal year. It covers the two-year obligation and expenditure period. Table 5a 

excludes Expenditures for Systems Development/Non-Direct Service Activities (formerly known as Resource Development Expenditures), 

which are located on SUPTRS BG Table 6. 

SUPTRS BG Table 5b - SUPTRS BG Primary Prevention Targeted Priorities. This required table provides a report of actual state primary 

prevention priorities and special population categories on which the state expended primary prevention funds from the SUPTRS BG NoA for 

the applicable fiscal year. 

SUPTRS BG Table 6 - Expenditures for System Development/Non-Direct Service Activities. This table provides a report of expenditures 

from the SUPTRS BG NoA for system development and non-direct service activities that were supported by the SUPTRS BG NoA for the 

applicable fiscal year. 

SUPTRS BG Table 7 - SUPTRS BG Statewide Entity Inventory. This table provides a report of the SUPTRS BG sub-recipients including 

community and faith-based organizations which provided SUD prevention activities and treatment services, along with 

intermediaries/administrative service organizations. Table 7 excludes Expenditures for Systems Development/Non-Direct Service Activities 

(formerly known as Resource Development Expenditures). 

SUPTRS BG Table 8a - Maintenance of Effort for State Expenditures for Substance Use Disorder Prevention, Treatment, and Recovery. 

This table provides a report of aggregate state expenditures by the SSA for authorized activities to prevent and treat SUDs during the state 

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

SUPTRS BG Table 8b - Base and Maintenance of Effort for Expenditures for Services to Pregnant Women and Women with Dependent 

Children. This table provides a report of SUPTRS BG and/or state funds pursuant to 42 U.S.C. § 300x-22(b) and 45 CFR § 96.124(c)(3) 
 

 

 

 

expended to establish new programs or expand the capacity of existing programs designed to serve pregnant women and women with 

dependent children and the services required pursuant to 45 CFR § 96.124(e) to address the treatment and recovery needs of such women 

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

SUPTRS BG Table 2 - State Agency Expenditure Report 

This table provides a report of SUPTRS BG and state expenditures by the SSA during the SFY immediately preceding the FFY for which the state is 

applying for funds for authorized activities to prevent and treat SUDs. For detailed instructions, refer to those in the WebBGAS. Please note that 

this expenditure period is different from that on SUPTRS BG Table 4. 
 

 

 

 

 

 – 

State Agency Expenditure Report 

SUPTRS BG Table 2 

State Identifier: 

Report Period- From: To: 

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

Source of Funds 

ACTIVITY 

(See instructions for using Row 

1) 

A. 

SUPTRS 

BG 

B. 

MHBG 

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 

H.

COVID –

19 1 

I. 

ARP2 

1. Substance Use Disorder

Prevention3 (Other than Primary

Prevention), Treatment, and 

Recovery

a. Pregnant Women and 

Women with Dependent 

Children 

b. Recovery Support

Services

c. All Other

2. Substance Use Disorder

Primary Prevention 

3. Tuberculosis Services
 

 

4. Early Intervention Services

Regarding the Human

Immunodeficiency Virus

(EIS/HIV)4 

5. Administration (Excluding

Program and Provider Level) 

6. Total

Please indicate if the expenditures 

are actual or estimated 

Actual Estimated 

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the “standard” 

SUPTRS BG and MHBG. However, grantees are requested to annually report SUPTRS BG COVID-19 Supplemental Funding expenditures in accordance with requirements included in 

their current Notice of Award Terms and Conditions (NoA). Per the instructions, the standard SUPTRS BG expenditures are for the state planned expenditure period of July 1, 2023 – June 

30, 2025 for most states. 2The expenditure period for ARP supplemental funding is September 1, 2021 – September 30, 2025, which is different from the expenditure period for the “standard” MHBG/SUPTRS BG. 

Per the instructions, the planning period for standard MHBG/SUPTRS BG expenditures is July 1, 2023 – June 30, 2025. 3 Prevention other than primary prevention. 4 Only designated states as defined in 42 U.S.C. § 300x-24(b)(2) and 45 CFR § 96.128(b) for the applicable federal fiscal year should enter information in this row. This may include a state 

or states that were previously considered “designated states” during any of the three prior FFYs for which a state was applying for a grant. See EIS/HIV policy change in SUPTRS BG 

Annual Report instructions. 
 

 

SUPTRS BG Table 3 – Syringe Services Program (SSP) 

Table 3 provides a report of SUPTRS BG and state expenditures by the SSA during theSFY immediately preceding the FFY 

for which the state is applying for funds for authorized activities to prevent and treat SUDs. For detailed instructions, refer to 

those in the WebBGAS. 
SUPTRS BG Table 3a – Syringe Services Program (SSP) 

Report Period 

State Identifier 

SSP Expenditures 

SSP Agency 

Name 

SSP Main 

Address 

SUD Treatment 

Provider (Yes 

or No) 

# of Locations 

(include any 

mobile 

locations) 

SUPTRS BG 

Funds 

COVID191 

Funds 

ARP 

Funds 

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the 

“standard” SUPTRS BG and MHBG. However, grantees are requested to annually report SUPTRS BG COVID-19 Supplemental Funding expenditures in accordance with 

requirements included in their current Notice of Award Terms and Conditions. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPTRS BG Table 3b - Syringe Services Program 

SUPTRS BG 

Syringe Services 

Program Name 

# of Unique 

Individuals Served 

HIV 

Testing 

(Please enter total 

number of individuals 

served) 

Treatment for Substance 

Use Conditions 

(Please enter total number 

of individuals served) 

Treatment for Physical 

Health 

(Please enter total 

number of individuals 

served) 

STD 

Testing 

(Please enter total 

number of 

individuals served) 

Hep C 

(Please enter total 

number of individuals 

served) 

ONSITEtestingREFERRAL totestingONSITEtreatmentREFERRAL totreatmentONSITEtreatmentREFERRAL totreatment

ONSITE

testing

REFERRAL totesting

ONSITEtesting

REFERRAL totesting 

COVID-191 

Syringe Services 

Program Name 

# of Unique Individuals 

Served 

HIV 

Testing 

(Please enter total number 

of individuals 

served) 

Treatment for Substance 

Use Conditions 

(Please enter total number 

of individuals served) 

Treatment for Physical 

Health 

(Please enter total number 

of individuals 

served) 

STD 

Testing 

(Please enter total number 

of individuals served) 

Hep C 

(Please enter total number 

of individuals served) 

ONSITEtestingREFERRAL totesting

ONSITEtreatmentREFERRAL totreatmentONSITEtreatmentREFERRAL totreatment

ONSITEtesting

REFERRAL totesting

ONSITE testingREFERRAL totesting 
 

 

 

 

 

 

 

 

 

 

ARP2 

Syringe Services 

Program Name 

# of Unique Individuals 

Served 

HIV Testing 

(Please enter 

total number of individuals 

served) 

Treatment for Substance 

Use Conditions 

(Please enter 

total number of individuals 

served) 

Treatment for Physical 

Health 

(Please enter total number 

of individuals served) 

STD 

Testing 

(Please enter total number 

of individuals served) 

Hep C 

(Please enter total 

number of individuals 

served) 

ONSITEtestingREFERRAL totesting

ONSITEtreatmentREFERRAL totreatmentONSITEtreatmentREFERRAL totreatment

ONSITEtesting

REFERRAL totesting

ONSITE testingREFERRAL totesting 

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the 

“standard” SUPTRS BG and MHBG. However, grantees are requested to annually report SUPTRS BG COVID-19 Supplemental Funding expenditures in accordance with 

requirements included in their current Notice of Award Terms and Conditions.

2 The expenditure period for ARP supplemental funding is September 1, 2021 – September 30, 2025, which is different from the expenditure period for the “standard” MHBG/SUPTRS 

BG. Per the instructions, the planning period for standard MHBG/SUPTRS BG expenditures is July 1, 2023 – June 30, 2025. 
 

SUPTRS BG Table 3c – Harm Reduction Activities 

Report Period 

State Identifier 

Harm Reduction Activities Expenditures 

Provider/Program Name Main Address SSP 

(Yes/No) 

Number of 

Naloxone 

Kits 

Purchased 

Number of 

Naloxone 

Kits 

Distributed 

Number 

of 

Overdose 

Reversals 

Number of 

Fentanyl Test 

Strips Purchased 

Number of 

Fentanyl Test 

Strips 

Distributed 

SUPTRS 

BG Funds 

COVID191 

Funds 

ARP 

Funds2 

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the 

“standard” SUPTRS BG and MHBG. However, grantees are requested to annually report SUPTRS BG COVID-19 Supplemental Funding expenditures in accordance with 

requirements included in their current Notice of Award Terms and Conditions.

2 The expenditure period for ARP supplemental funding is September 1, 2021 – September 30, 2025, which is different from the expenditure period for the “standard” MHBG/SUPTRS 

BG. Per the instructions, the planning period for standard MHBG/SUPTRS BG expenditures is July 1, 2023 – June 30, 2025. 
 

 

SUPTRS BG Table 4 - State Agency SUPTRS BG Expenditure Compliance Report 

This table provides a description of SUPTRS BG expenditures for authorized activities to prevent and treat SUDs. For detailed instructions, 

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

State Agency SUPTRS BG Expenditure Compliance Report 

SUPTRS BG Table 4 

State Identifier: 

Expenditure Category 

FY 2021 SUPTRS BG 

Award 

FY 2022 SUPTRS BG Award 

1. Substance Use Disorder Prevention,

1 Treatment, and Recovery 

2. Substance Use Disorder Primary Prevention 

3. Early Intervention Services Regarding the Human Immunodeficiency Virus 

(EIS/HIV)2 

4. Tuberculosis Services 

5. Administration (excluding program / provider level) 

6. Total 

1 Prevention other than Primary Prevention 

2 Only designated states as defined in 42 U.S.C. § 300x-24(b)(2) and 45 CFR § 96.128(b) for the applicable federal fiscal year should enter information in this row. This 

may include a state or states that were previously considered “designated states” during any of the three prior FFYs for which a state was applying for a grant. See 

EIS/HIV policy change in SUPTRS BG Annual Report instructions 
 

 

 

 

SUPTRS BG Table 5a - Primary Prevention Expenditures 

The state or jurisdiction must complete SUPTRS BG Table 5a. There are six primary prevention strategies typically funded by principal 

agencies administering the SUPTRS BG. 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 plans to use strategies not covered by 

these six categories or the state is unable to calculate expenditures by strategy, please report them under “Other” in Table 5a. 

The state or jurisdiction must complete SUPTRS BG Table 5a Other Strategy if it chooses to report SUD primary prevention activities 

utilizing the IOM Model of Universal, Selective, and Indicated. Indicate how much funding supported each of the IOM classifications of 

Universal Direct, Universal Indirect, Selective, or Indicated without specifying the prevention strategy. Include all funding sources (e.g., 

Centers for Disease Control and Prevention Block Grant, foundations). For detailed instructions, refer to those in the WebBGAS. 

Section 1926 (Synar) - Tobacco: Costs associated with the Synar Program. Pursuant to the January 19, 1996 federal regulation “Tobacco 

Regulation for Substance Use Prevention and Treatment Block Grants, Final Rule” (45 CFR § 96.130) a state may not use the SUPTRS BG 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 

CFR § 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 any non-SUPTRS BG funds* that were allotted for Synar activities in the appropriate 

columns under 7 below. Public Law 116-94, signed on December 20, 2019, supersedes this legislation and increased the minimum age for 

tobacco sales from 18 to 21. SAMHSA revised its guidance to clarify that the prevention set aside may be used to fund revisions to states’ 

Synar program to comply with PL 116-94. These funds should be reported in the appropriate columns under 7 below. 

In most cases the total SUPTRS BG amounts should equal the amounts reported on Plan Table 4, Row 2, Substance Use Disorder Primary 

Prevention. The one exception is if the state chooses to use a portion of the primary prevention set-aside to fund Non-Direct Services/System 

Development activities. The total on the Table 6 prevention column combined with the total on Table 5a should equal to expenditure Table 4, 

Row 2 in most instances. 

Institute of Medicine Classification: Universal, Selective, and Indicated: 

Prevention strategies may be classified using the IOM Model of Universal, Selective, and Indicated, which classifies preventive 

interventions by the population targeted. Definitions for these categories appear below: 

Universal: Activities targeted to the public or a whole population group that have not been identified based on individual risk. 
 

 

 

 

 

 

Universal Direct: Row 1 - Interventions directly serve an identifiable group of participants who have not been identified on the basis of 

individual risk (e.g., school curriculum, after-school program, parenting class). This also could include interventions involving interpersonal 

and ongoing/repeated contact (e.g., coalitions). 

Universal Indirect: Row 2 - Interventions support population-based programs and environmental strategies (e.g., establishing, Alcohol, 

Tobacco, and Other Drugs (ATOD) policies, modifying ATOD advertising practices). This also could include interventions involving 

programs and policies implemented by coalitions. 

Selective: Activities targeted to individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than 

average. 

Indicated: Activities targeted to individuals in high-risk environments, identified as having minimal but detectable signs or symptoms 

foreshadowing disorder or having biological markers indicating predisposition for disorder but not meeting diagnostic levels (Adapted from 

The Institute of Medicine). 

States that can report on both the strategy type and the population served (universal, selective, or indicated) should do so. If planned 

expenditure information is only available by strategy type, then the state should report planned expenditures in the row titled Unspecified (for 

example, Information Dissemination Unspecified). 

Substance Use Disorder Primary Prevention Strategies Defined: 

Information Dissemination – This strategy provides knowledge and increases awareness of the nature and extent of alcohol and 

other drug use, abuse, and addiction, as well as their effects on individuals, families, and communities. It also provides 

knowledge and increases awareness of available prevention and treatment programs and services. It is characterized by one-way 

communication from the source to the audience, with limited contact between the two. 

Education - This strategy builds skills through structured learning processes. Critical life and social skills include decision 

making, peer resistance, coping with stress, problem solving, interpersonal communication, and systematic and judgmental 

abilities. There is more interaction between facilitators and participants than in the information strategy. 
 

 

Alternatives - This strategy provides participation in activities that exclude alcohol and other drugs. The purpose is to meet the 

needs filled by alcohol and other drugs with healthy activities and to discourage the use of alcohol and drugs through these 

activities. 

Problem Identification and Referral to Education - This strategy aims at identification of those who have indulged in 

illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order 

to assess if their behavior can be reversed through education. It should be noted, however, that this strategy does not include any 

activity designed to determine if a person needs treatment. 

Community-based Process - This strategy provides ongoing networking activities and technical assistance to community groups 

or agencies. It encompasses neighborhood-based, grassroots empowerment models using action planning and collaborative 

systems planning. 

Environmental - This strategy establishes, or changes written and unwritten community standards, codes, and attitudes; thereby, 

influencing alcohol and other drug use by the general population. 

Other - States that plan their primary prevention expenditures using the IOM model of universal, selective, and indicated should 

use Table 5a to list their FFY 2022 and FFY 2023 SUPTRS BG planned expenditures in each of these categories. 
 

 

 

 

 

 

 

SUPTRS BG Primary Prevention Expenditures 

SUPTRS BG Table 5a 

State Identifier: 

Report Period- From: To: 

Strategy A. 

IOM Target 

B. 

Substance Use Block 

Grant 

C. 

Other Federal 

D. 

State 

E. 

Local 

F. Other 

1. Information Dissemination Universal $ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

Unspecified $ $ $ $ $ 

2. Education Universal $ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

Unspecified $ $ $ $ $ 

3. Alternatives Universal $ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

Unspecified $ $ $ $ $ 

4. Problem Identification and

Referral 

Universal $ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

Unspecified $ $ $ $ $ 

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

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

Unspecified $ $ $ $ $ 
 

 

 

 

 

6. Environmental Universal $ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

Unspecified $ $ $ $ $ 

7. Section 1926 (Synar)-Tobacco Universal $ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

8. Other Universal Direct $ $ $ $ $ 

Universal 

Indirect 

$ $ $ $ $ 

Selective $ $ $ $ $ 

Indicated $ $ $ $ $ 

10. Total $ $ $ $ $ 

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

 

 

SUPTRS BG Table 5b (Required) - SUPTRS BG 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 2021 SUPTRS BG NoA. 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. 

SUPTRS 

BG Award 

Prioritized Substances 

Alcohol 

 

Tobacco 

 

Marijuana 

 

Prescription Drugs 

 

Cocaine 

 

Heroin 

 

Inhalants 

 

Methamphetamine 

 

Synthetic Drugs (i.e. Bath salts, Spice, K2) 

 

Fentanyl 

Prioritized Populations 

Students in College 

 

Military Families 

 

LGBTQ+ 

 
 

American Indians/Alaska Natives 

 

African American 

 

Hispanic 

 

Homeless 

 

Native Hawaiian/Other Pacific Islanders 

 

Asian 

 

Rural 

 

Other Underserved Racial and Ethnic Minorities 

 
 

 

 

SUPTRS BG/MHBG Table 6 - Non-Direct-Services/System Development 

Proposed Categories for Expenditures for System Development/Non-Direct-Service Activities 

Expenditures in the following categories of activities may involve the time of state or sub-state personnel, or may be funded through 

contracts, grants, or agreements with other entities. Expenditures may come from the administrative funds and/or program funds (but may not 

include the HIV set-aside funds). Please utilize the following categories to describe the types of expenditures your state supports with Block 

Grant funds, and if the preponderance of the activity fits within a category. 

We understand that a particular activity may cross categories but try to identify the primary purpose or goal of the activity. For example, a 

state may utilize Block Grant funds to train personnel to conduct fidelity assessments of evidence-based practices. While this could fall under 

either training/education and/or quality assurance/improvement – the primary purpose is to assure the implementation of evidence-based 

practices (EBP), so that expenditure would most likely be captured under quality assurance/improvement. 

Information Systems – This includes collecting and analyzing treatment data as well as prevention data under the SUPTRS BG to monitor 

performance and outcomes. Costs for electronic health records and other health information technology also fall under this category. 

Infrastructure Support – This includes activities that provide the infrastructure to support services but for which there are no individual 

services delivered. Examples include the development and maintenance of a crisis-response capacity, including hotlines, mobile crisis teams, 

web-based check-in groups (for medication, treatment, re-entry follow-up), drop-in centers, and respite services. 

Partnerships, Community Outreach, and Needs Assessment – This includes state, regional, and local personnel salaries prorated for time 

and materials to support planning meetings, information collection, analysis, and travel. It also includes the support for partnerships across 

state and local agencies, and tribal governments. Community/network development activities, such as marketing, communication, and public 

education, and including the planning and coordination of services, fall into this category, as do needs-assessment projects to identify the 

scope and magnitude of the problem, resources available, gaps in services, and strategies to close those gaps. 

Planning Council Activities – This includes those supports for the performance of a Mental Health Planning Council under the MHBG, a 

combined Behavioral Health Planning Council, or optional Advisory Council for the SUPTRS BG. 

Quality Assurance and Improvement – This includes activities to improve the overall quality of services, including those activities to 

assure conformity to acceptable professional standards, adaptation, and review of implementation of EBP, identification of areas of technical 

assistance related to quality outcomes, including feedback. Administrative agency contracts to monitor service-provider quality fall into this 

category, as do independent peer-review activities. 
 

- 

 

- 

 

 

 

 

 

Research and Evaluation – This includes performance measurement, evaluation, and research, such as services research and demonstration 

projects to test feasibility and effectiveness of a new approach as well as the dissemination of such information. 

Training and Education– This includes skill development and continuing education for personnel employed in local programs as well as 

partnering agencies, as long as the training relates to either substance use disorder service delivery (prevention, treatment, and recovery) for 

SUPTRS BG and services to adults with SMI or children with SED for MHBG. Typical costs include course fees, tuition, and expense 

reimbursements to employees, trainer(s) and support staff salaries, and certification expenditures. 

Please enter the total amount of the block grant expended for each activity. 

Non-Direct Services/System Development

SUPTRS BG Table 6 

State Identifier: 

Report Period- From: To: 

Activity A. MHBG B. SUPTRS 

BG 

Treatment 

C. SUPTRS BG 

Prevention 

D. SUPTRS BG 

Integrated 1 

1. Information Systems $ $ $ $ 

2. Infrastructure Support $ $ $ $ 

3. Partnerships, Community Outreach, and Needs Assessment $ $ $ $ 

4. Planning Council Activities (MHBG required, SUPTRS BG

optional) $ $ $ $ 

5. Quality Assurance and Improvement $ $ $ $ 

6. Research and Evaluation $ $ $ $ 

7. Training and Education $ $ $ $ 

8. Total $ $ $ $ 

1 Integrated refers to funds both treatment and prevention portions of the SUPTRS BG for overarching activities. 
 

 

- 

 

SUPTRS BG Table 7 – State Entity Inventory 

This table provides a report of the sub-recipients of SUPTRS BG funds including community and faith-based organizations which provided 

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

development/non-direct service expenditures. For detailed instructions, see those in WebBGAS. 

Statewide Entity Inventory 

SUPTRS BG Table 7 

State Identifier: 

Report Period- From: To: 

Source of Funds 

Substance Use Block Grant 

A B C D E F G1 H 

Entity 

Number 

I-BHS ID 

(formerly 

I-SATS) 

Area 

Served 

(Statewide 

or SubState 

Planning 

Area) 

Provider/Program 

Name 

Street 

Address 

City State Zip All 

SUPTRS 

BG 

Funds 

Prevention 

(other than 

Primary 

Prevention) 

and 

Treatment 

Services 

Pregnant 

Women 

and 

Women 

with 

Dependent 

Children 

Primary 

Prevention 

Early 

Intervention 

Services for 

HIV 

Syringe 

Services 

Program 

Opioid 

Treatment 

Programs 

(OTPs) 

Officebased 

opioid 

treatment 

programs 

(OBOTs) 

$ $ $ $ $ $ $ $ 

$ $ $ $ $ $ $ $ 

Total $ $ $ $ $ $ $ $ 

1 Note: 42 CFR 8.12: Federal Opioid Treatment Standards (OTP) providers only 
 

 

 

 

 

 

 

 

 

 

- 

 

Description of Calculations for MOE Tables 8a and 8b 

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

(a) total Single State Agency (SSA) expenditures for SUD prevention and treatment as required by: 

a. 42 U.S.C. § 300x-30 and 45 CFR § 96.124(f)(4)

(b) the base and, for 1994 and subsequent fiscal years, report the federal and state expenditures for services to pregnant women 

and women with dependent children as required by: 

b. 42 U.S.C. § 300x-22(b)(1) and 45 CFR § 96.122(f)(5)(ii)(A)

SUPTRS BG Table 8a - Maintenance of Effort for State Expenditures for SUD Prevention, Treatment, and Recovery 

This Maintenance of Effort table provides a description of non-federal state expenditures for authorized activities to prevent and treat 

substance use and provide recovery services 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 FFY 2024 SUPTRS BG Report. For the 

FFY 2025 SUPTRS BG report, please increase each year by one. For detailed instructions, see those in BGAS. 

SUPTRS BG Table 8a Total Single State Agency (SSA) Expenditures for Substance Use Prevention, 

Treatment, and Recovery Services 

State Identifier: 

Report Period- From: To: 

Period 

(A) 

Expenditures 

(B) 

B1 (2020) + B2 (2021) 

2 

(C) 

SFY 2021 

(1) 

SFY 2022 

(2) 

SFY 2023 

(3) 

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

Yes No 

SFY 2021 

SFY 2022 

SFY 2023 
___ 

 

 

 ___ ___ _____ 

____ 

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 as described in 42 U.S.C. § 300x-30(b) for a specific purpose which were 

not included in the MOE calculation? 

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

Did the state or jurisdiction include these funds in previous year MOE calculations? Yes No___ 

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

 mm/dd/yyyy 
 

G Table 8c SUPTRS BG Table 8c SUPTRS BG Table 8c 

 

- 

SUPTRS BG Table 8b - Expenditures for Services to Pregnant Women and Women with Dependent Children 

This table provides a report of all statewide, non-federal funds expended on specialized treatment and related services which meet the 

SUPTRS BG requirements for pregnant women and women with dependent children during the state fiscal year immediately preceding the 

FFY for which the state is applying for funds. Dates given are for the FY 2024 SUPTRS BG Report. For the FY 2025 SUPTRS BG Report, 

increase each year (other than the base year) by one. For detailed instructions, see those in WebBGAS. 

Expenditures for Services to Pregnant Women and Women with Dependent Children 

SUPTRS BG Table 8b 

State Identifier: 

Report Period- From: To: 

Period Total Women’s Base 

(A) 

Total Expenditures 

(B) 

1994 

2021 

2022 

2023 
 

 

 

 

 

 

 

 

 

 

 

 

D. Populations and Services Report 

States are required to provide information regarding individuals that are served by the SSA in SUPTRS BG Tables 9 through 13. 

SUPTRS BG 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 (42 U.S.C. § 300x-29) about the primary prevention activities 

conducted by the entities listed on SUPTRS BG 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 subpopulations at risk for ATOD. 

SUPTRS BG Table 10a - 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 Behavioral Health Services 

Information System (BHSIS), formerly known as the Drug and Alcohol Services Information System (DASIS), Treatment Episode Data Set (TEDS) standards (see TEDS data) during the SFY immediately preceding the FFY for 

which the state is applying for funds. 

SUPTRS BG Table 10b – Number of Persons Served (Unduplicated Count) Who Received Recovery Supports. This table captures an aggregated unduplicated count of persons who receive recovery support services using SUPTRS 

BG funds during the SFY immediately preceding the FFY for which the state is applying for funds. Grantees are to provide counts of persons that have received specified recovery support services. Grantees should provide this 

information for individuals who received recovery support services by age and gender. 

SUPTRS BG Table 11a - 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 SUPTRS BG during the SFY immediately preceding the FFY for which the state is applying for funds. States are to provide this information on all programs by age, gender, and race/ethnicity. States are to report 

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

SUPTRS BG Table 11b - COVID-19 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 with COVID-19 Relief Supplement funds during the SFY immediately preceding the FFY for which the state is applying for funds. States are to provide this information on all programs by age, gender, and race/ethnicity. 

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

SUPTRS BG Table 11c - Sexual Orientation 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 SUPTRS BG during the SFY immediately preceding the FFY for which the state is applying for funds by sexual orientation and age. States are to report whether the values reported come from a clientbased system(s) with unique client identifiers. 

SUPTRS BG Table 12 - SUPTRS BG Designated States and Early Intervention Services Regarding the Human Immunodeficiency Virus. This table requires designated states as defined in section 1924(b)(2) of Title XIX, Part B, 

Subpart II of the PHS Act (42 U.S.C. § 300x-24(b)(2)), to provide information on Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV) provided during the state fiscal year immediately preceding 

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

SUPTRS BG Table 13 - Charitable Choice. This table requires states 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 CFR Part 54) during the state fiscal year immediately preceding the federal fiscal year for which the state is applying for funds. Each section of this table requires that the state respond 

appropriately to identify the way they have complied with the requirements related to authorizing legislation and implementing regulation. States should report on the number of clients referred due to religious objection from faith 

and community-based programs to appropriate alternative providers. If no alternate referrals were made, enter zero. 
SUPTRS BG 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 (42 U.S.C.§ 300x29) about the primary prevention activities conducted by the entities listed on SUPTRS BG Table 7. For detailed instructions, see those

in BGAS. 

Prevention Strategy Report Risk-Strategies

SUPTRS BG Table 9 

Report Period- From: To: 

State Identifier 

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

Children of People who Misuse Substances [1] 

Pregnant Women/Teens [2] 

People Who End High School Pre-Graduation [3] 

Violent and Delinquent Behavior [4] 

Mental Health Problems [5] 

Economically Disadvantaged [6] 

People with Differing Physical Abilities [7] 

People Who Experience Abuse [8] 

Already Using Substances [9] 

People With Housing Insecurity [10] 

Other- Specify [11] 
 

-

-

 

 -

 

 

 

SUPTRS BG Table 10a – 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 WebBGAS. 

SUPTRS BG Table 10 a 

Report Period- From: To: Treatment Utilization Matrix 

SUPTRS BG Number of Admissions 

≥ 

Number of Persons Served 

COVID-19 Number of Admissions 

≥ Number of Persons Served 1 

ARP Number of Admissions ≥ 

Number of Persons Served 2

SUPTRS BG Service Costs COVID-19 Costs 1 ARP Costs 2 

Level of Care 

Number 

of Admissions 

(A) 

Number of 

Persons Served 

(B) 

Number 

of Admissions 

(C) 

Number of 

Persons Served 

(D) 

Number 

of Admissions 

(E) 

Number of 

Persons Served 

(F) 

Mean 

(G) 

Median 

(H) 

Standard 

Deviation 

(I) 

Mean Cost 

(J) 

Median Cost 

(K) 

Standard 

Deviation 

(L) 

Mean Cost 

(M) 

Median Cost 

(N) 

Standard 

Deviation 

(O) 

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 $ $ $ $ $ $ $ $ $ 

MOUD & Medication Assisted Treatment3 

9. MOUD Medication-Assisted

Detoxification $ $ $ $ $ $ $ $ $ 

10. MOUD Medication-Assisted

Treatment Outpatient $ $ $ $ $ $ $ $ $ 

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the “standard” SUPTRS BG and MHBG. However, grantees are requested to annually report SUPTRS BG COVID-19 Supplemental 

Funding expenditures in accordance with requirements included in their current NoA Terms and Conditions. 2The expenditure period for ARP Supplemental funding is September 1, 2021 – September 30, 2025, which is different from the expenditure period for the “standard” MHBG/SUPTRS BG. Per the instructions, the planning period for standard MHBG/SUPTRS BG expenditures is July 1, 2023 – June 30, 

2025. 

3 In FY 2020 SAMHSA modified the “Level of Care" (LOC)” and "Type of Treatment Service/Setting" to “Medication-Assisted Treatment” and “Medication- Assisted Treatment,” respectively. In prior SUPTRS BG Reports, the LOC was entitled "Opioid Replacement Therapy" and the Type of 

Treatment Service/Setting included "Opioid Replacement Therapy," Row 9 and "ORT Outpatient," Row 10. The changes inadvertently created a barrier for data analysis as one-to-one mapping of the data submitted in the FY 2020 Table 10 to the data submitted in prior Reports is not possible. In 

the current and future SUPTRS BG Reports, the LOC is "MOUD & Medication Assisted Treatment" and the Types of Treatment Service/Setting will include "MOUD Medication-Assisted Treatment Detoxification," Row 9 and "MOUD & Medication Assisted Treatment Outpatient," Row 10. 

MOUD & Medication-Assisted Treatment Detoxification includes hospital detoxification, residential detoxification, or ambulatory detoxification services/settings AND Opioid Medication-Assisted Treatment. MOUD & Medication Assisted Treatment Outpatient includes outpatient 

services/settings AND Opioid Medication-Assisted Treatment. The change was made to better align with language that reflects not all medications used to treat opioid use disorder (OUD) are opioid-based and more importantly convey those medications do not merely substitute one drug for another. 
r 

: 

SUPTRS BG Table 10b – Number of Persons Served (Unduplicated Count) Who Received Recovery Supports 

This table provides an aggregate profile of the unduplicated persons that received recovery support services funded through the SUPTRS BG by age and gender identity. For detailed instructions, see those in WebBGAS. 

SUPTRS BG Table 10b 

Reporting Period: From: To: 

State Identifier: 

Age 0-51 Age 6-12 Age 13-17

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other Not 

Available 

Peer-to-Peer Support 

Individual 

Peer-Led Support Group 

Peer-Led Training or Peer 

Certification Activity 

Recovery Housing 

Recovery Support Service 

Childcare Fee or Family 

Caregiver Fee 

Recovery Support Service 

Transportation 

Secondary School, High 

School, or Collegiate 

Recovery Program Service o

Activity 

Recovery Social Support or 

Social Inclusion Activity 

Other SAMHSA Approved 

Recovery Support Event or 

Activity 

Comments on Data (Age): 

Comments on Data (Gender)

Comments on Data (Overall):

1 Age category 0-5 years is not applicable. 
- - -

 

 

 

(Continued below) 

SUPTRS BG (Cont.) 

Reporting Period: From: To: 

State Identifier: 

Age 18-20 Age 21-24 Age 25-44

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

Peer-to-Peer Support Individual 

Peer-Led Support Group 

Peer-Led Training or Peer 

Certification Activity 

Recovery Housing 

Recovery Support Service 

Childcare Fee or Family 

Caregiver Fee 

Recovery Support Service 

Transportation 

Secondary School, High School, 

or Collegiate Recovery Program 

Service or Activity 

Recovery Social Support or 

Social Inclusion Activity 

Other SAMHSA Approved 

Recovery Support Event or 

Activity 

(Continued on next page) 
- -

 

 

 

 

 

 

SUPTRS BG (Cont.) 

Reporting Period: From: To: 

State Identifier: 

Age 45-64 Age 65-74 Age 75+ 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

Peer-to-Peer Support Individual 

Peer-Led Support Group 

Peer-Led Training or Peer 

Certification Activity 

Recovery Housing 

Recovery Support Service 

Childcare Fee or Family 

Caregiver Fee 

Recovery Support Service 

Transportation 

Secondary School, High School, 

or Collegiate Recovery Program 

Service or Activity 

Recovery Social Support or 

Social Inclusion Activity 

Other SAMHSA Approved 

Recovery Support Event or 

Activity 

SUPTRS BG (Cont.) 

Reporting Period: From: To: 

State Identifier: 

Age Not Available Total 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Total 

Peer-to-Peer Support Individual 

Peer-Led Support Group 

Peer-Led Training or Peer 

Certification Activity 

Recovery Housing 

Recovery Support Service 

Childcare Fee or Family 

Caregiver Fee 

Recovery Support Service 

Transportation 

Secondary School, High School, 

or Collegiate Recovery Program 

Service or Activity 

Recovery Social Support or 

Social Inclusion Activity 
Other SAMHSA Approved 

Recovery Support Event or 

Activity 
 

 

 

 ☐

SUPTRS BG Table 11a - 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 SUPTRS BG. This table should not include persons served using COVID-19 Relief Supplemental 

Funding. For detailed instructions, see those in BGAS. 

SUPTRS BG 

Table 11A 

Reporting Period: From: To: 

State Identifier: 

Total American Indian or Alaska Native Asian 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Total Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years1 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

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 

SUPTRS BG 

Table 10 

Are the values reported in this table generated from a client-based system with unique client identifiers? Yes ☐ No 

Comments on 

Data (Race): 

Comments on 

Data (Gender): 

Comments on 

Data (Overall): 

1 Age category 0-5 years is not applicable. 
 

SUPTRS BG 

Table 11A (cont) 

Reporting Period: From: To: 

State Identifier: 

Black or African American Native Hawaiian or Other Pacific Islander White 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 

SUPTRS BG 

Table 11A (cont) 

Reporting Period: From: To: 

State Identifier: 

Some Other Race More than One Race Reported Race Not Available 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 
SUPTRS BG 

Table 11A (cont) 

Reporting Period: From: To: 

State Identifier: 

Not Hispanic or Latino Hispanic or Latino Hispanic or Latino Origin Not Available 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years1 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 

1 Age category 0-5 years is not applicable. 
 

 

 

Table 11b- COVID-19 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 using COVID-19 Relief Supplemental Funding. For detailed instructions, see those in BGAS. 

SUPTRS BG 

Table 11B 

Reporting Period1: From: To: 

State Identifier: 

Total American Indian or Alaska Native Asian 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Total Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years2 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 

Comments on 

Data (Race): 

Comments on 

Data (Gender): 

Comments on 

Data (Overall): 

1

The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the “standard” SUPTRS BG and MHBG. However, grantees are requested to annually report SUPTRS BG COVID-19 Supplemental 

Funding expenditures in accordance with requirements included in their current NoA Terms and Conditions.

2 Age category 0-5 years is not applicable. 
SUPTRS BG 

Table 11B (cont.) 

Reporting Period: From: To: 

State Identifier: 

Black or African American Native Hawaiian or Other Pacific Islander White 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years1 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 

1 Age category 0-5 years is not applicable. 

SUPTRS BG 

Table 11B (cont.) 

Reporting Period: From: To: 

State Identifier: 

Some Other Race More than One Race Reported Race Not Available 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years1 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 

1 Age category 0-5 years is not applicable. 
SUPTRS BG 

Table 11B (cont.) 

Reporting Period: From: To: 

State Identifier: 

Not Hispanic or Latino Hispanic or Latino Hispanic or Latino Origin Not Available 

Female Male 

Transgender

(Trans

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available Female Male 

Transgender

(Trans 

Woman) 

Transgender

(Trans

Man) 

Gender 

NonConforming Other 

Not 

Available 

0-5 years1 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ 

Not Available 

Total 

Pregnant Women 

1 Age category 0-5 years is not applicable. 
 

SUPTRS BG TABLE 11c: Sexual Orientation Unduplicated Count of Persons Served for Alcohol and Other Drugs 

Sexual Orientation 

A. AGE I. Straight or 

Heterosexual 

J. 

Homosexu 

al (Gay or 

Lesbian) 

K. 

Bisexual 

L. Queer M. Pansexual N. 

Questioning 

O. Asexual P. Other Q. Not 

Available 

0 – 5 years1 

6-12 years 

13-17 years 

18-20 years 

21-24 years 

25-44 years 

45-64 years 

65-74 years 

75+ years 

TOTAL 

1 Age category 0-5 years is not applicable. 
 

-

 

 

 

 

 

 

 

 

 

 

SUPTRS BG Table 12 - SUPTRS BG Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV) in Designated States 

For detailed instructions, see those in BGAS. 

SUPTRS BG Table 12 

Report Period- From: To: 

State Identifier: 

Early Intervention Services Regarding the Human Immunodeficiency Virus (EIS/HIV) 

1. Number of EIS/HIV projects among SUPTRS BG sub-recipients in

the state: 

Statewide:_____ Rural:_____ 

2. Total number of individuals tested through SUPTRS BG subrecipient EIS/HIV projects: 

3. Total number of HIV tests conducted with SUPTRS BG EIS/HIV 

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 

7. Total number of persons at risk for HIV/AIDS referred for PrEP

services? 

Identify barriers, including state laws and regulations, that exist in carrying out HIV testing services: 
 

 

 

 

 

SUPTRS BG Table 13 - Charitable Choice – Required 

Under Charitable Choice Provisions; Final Rule (42 CFR Part 54), 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 use disorder 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 Behavioral Health Treatment 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 use disorder 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. If no alternative referrals were made, enter zero. 

Provide a brief description (one paragraph) of any training for local governments and/or faithbased and/or community organizations that are providers on these requirements. 
 

 

 

 

 

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 

SUPTRS BG Table 14 - Employment/Education Status. This table describes the status of adult 

clients served by the public SUD treatment service systems 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 within the prior 30 days) at admission and 

discharge. 

SUPTRS BG 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. 

SUPTRS BG 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. 

SUPTRS BG 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. 

SUPTRS BG Table 18 - Change in Abstinence - Other Drug Use. This table collects 

information regarding clients’ change in abstinence with drugs of use 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. 

SUPTRS BG Table 19 - Change in Social Support of Recovery. This table seeks to measure the 

change in clients’ social support of recovery. Specifically, this form collects information 

regarding the number of clients participating in self-help groups at admission and discharge. 

SUPTRS BG 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 

SUPTRS BG Table 21 - Reduced Morbidity –Abstinence from Drug Use/Alcohol Use; Measure: 

30 Day Use. This table seeks information regarding 30-day use of alcohol, tobacco, and other 

drugs. 

SUPTRS BG 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. 

SUPTRS BG 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. 

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

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

attitude regarding use of alcohol, cigarettes, and other drugs. 

SUPTRS BG 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. 

SUPTRS BG Table 26 - Employment/Education; Measure: Average Daily School Attendance 

Rate. This table collects information regarding the average daily school attendance. 

SUPTRS BG 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. 

SUPTRS BG Table 28 - Crime and Criminal Justice; Measure: Alcohol and Drug Related 

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

SUPTRS BG 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 about alcohol and drug use. 

SUPTRS BG 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 messaging. 

SUPTRS BG Table 31-35 – Reporting Period – Start and End Dates for Information Reported 

on Tables 31, 32, 33, 34, and 35. This table provides information regarding the corresponding 

reporting period dates for Table 31 through Table 35. States also must describe their data 

collection system regarding prevention NOMS reporting. 

SUPTRS BG 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. 

SUPTRS BG 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 goaloriented practices, procedures, processes, or activities that have identifiable outcomes achieved 

with a sequence of steps subject to monitoring and modification. 

SUPTRS BG 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. 

SUPTRS BG 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. 

SUPTRS BG Table 35 - Number of Evidence-based Programs and Strategies, and Total 

SUPTRS BG Funds Spent on Evidence-Based Programs/ Strategies. This table collects 

information on the number of Evidence-Based Programs and Strategies funded by the type of 

IOM intervention (e.g. Universal, Selective, and Indicated). In addition, the state must indicate 

the amount of SUPTRS BG funds spent on the Evidence-Based interventions. 

SUPTRS BG 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) 
 

 

(SUPTRS BG Table 14) (continued) State Description of Employment/Education Status Data Collection 

STATE CONFORMANCE 

TO INTERIM STANDARD 

State Description of Employment/Education Data Collection (SUPTRS BG Table 14): 

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 SUPTRS BG Table 14 (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 SUPTRS BG Table 14 (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 SUPTRS BG Table 14 (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 are collected for the census of all (or almost all) clients who were admitted

to treatment □ Discharge data are 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 14 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using a 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 □ Providerentity-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 ARE 

UNAVAILABLE 

If data are 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 

ARE NOT AVAILABLE 

State must provide time-framed plans for capturing employment\student status data on all 

clients if data are not currently available. Plans should also discuss barriers, resource needs 

and estimates of cost. 

SUPTRS BG 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 

SUPTRS BG Table 15 – State Description of Stability in Housing Data Collection

STATE 

CONFORMANCE TO 

INTERIM STANDARD 

State Description of Stability in Housing Data Collection (SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 are collected for the census of all (or almost all) clients who were admitted to

treatment □ Discharge data are 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 SUPTRS BG Table 15 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using a 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 ARE 

UNAVAILABLE If data are not reported, why is the 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 

ARE NOT AVAILABLE 

State must provide time-framed plans for capturing criminal justice involvement status data on 

all clients if data are not currently available. Plans should also discuss barriers, resource needs 

and estimates of cost. 

SUPTRS BG 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 
 

_________________________________________________________ 

 _____________ 

–

 

 

 

DO NOT DISTRIBUTE – CLOSE HOLD 

State Description of Criminal Involvement Data Collection (SUPTRS BG Table 16) 

STATE 

CONFORMANCE TO 

INTERIM STANDARD 

State Description of Criminal Involvement Data Collection (SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 are collected for the census of all (or almost all) clients who were admitted to

treatment □ Discharge data are 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 SUPTRS BG Table 16 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using a 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 ARE 

UNAVAILABLE If data are 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 

ARE NOT AVAILABLE 

State must provide time-framed plans for capturing criminal justice involvement status data on 

all clients if data are not currently available. Plans should also discuss barriers, resource needs 

and estimates of cost. 

SUPTRS BG Table 17– Treatment 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 
 

 

 

 

 

– 

 

 

 

 

 

 

DO NOT DISTRIBUTE – CLOSE HOLD (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 01) 

State Description of Alcohol Use Data Collection (SUPTRS BG Table 17) 

STATE 

CONFORMANCE 

TO INTERIM 

STANDARD 

State Description of Alcohol Use Data Collection (SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 are collected for the census of all (or almost all) clients who were admitted to

treatment □ Discharge data are 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 SUPTRS BG Table 17 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using a 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 ARE 

UNAVAILABLE 

If data are 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 ARE NOT 

AVAILABLE 

State must provide time-framed plans for capturing abstinence - alcohol use status data on all 

clients if data are not currently available. Plans should also discuss barriers, resource needs and 

estimates of cost. 

SUPTRS BG 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 

*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 01-04) 
 

 

 

 _____________ 

DO NOT DISTRIBUTE – CLOSE HOLD 

SUPTRS BG Table 18 – State Description of Other Drug Use Data Collection 

STATE 

CONFORMANCE TO 

INTERIM STANDARD 

State Description of Other Drug Use Data Collection (SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 are collected for the census of all (or almost all) clients who were admitted to

treatment □ Discharge data are 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 SUPTRS BG Table 18 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using a 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 ARE 

UNAVAILABLE 

If data are 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 

ARE NOT AVAILABLE 

State must provide time-framed plans for capturing abstinence – drug use status data on all 

clients if data are not currently available. Plans should also discuss barriers, resource needs and 

estimates of cost. 

SUPTRS BG 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 selfhelp activities [denominator] 

Percent of clients participating in self-help activities 

SUPTRS BG Table 19 – State Description of Social Support of Recovery Data Collection 
 

 

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DO NOT DISTRIBUTE – CLOSE HOLD 

STATE 

CONFORMANCE TO 

INTERIM STANDARD 

State Description of Social Support of Recovery Data Collection (SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 are collected for the census of all (or almost all) clients who were admitted to

treatment □ Discharge data are 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 SUPTRS BG Table 19 (select all that apply): 

□ Yes, all clients at admission were linked with discharge data using a 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 ARE 

UNAVAILABLE 

If data are 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 

ARE NOT AVAILABLE 

State must provide time-framed plans for capturing self-help participation status data on all clients if 

data are not currently available. Plans should also discuss barriers, resource needs and estimates of 

cost. 

SUPTRS BG 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 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) 
 

 

 

 

 

 

 

 

DO NOT DISTRIBUTE – CLOSE HOLD 

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 

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 

SUPTRS BG application. For Tables 21-25 and 27-30, the compliance year is calendar year 

(CY) 2019 (note that pre-populated NOMs from the National Survey on Drug Use and Health 

(NSDUH) reflect pooled data from CYs 2018-2019. For substance use disorder prevention 

NOMs Table 26, the compliance year is School Year 2019. 

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

and the one Native American tribe that receive SUPTRS BG 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 

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 SUPTRS BG funding. These data will be pre

populated into the data tables by CSAP. 

-

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

 

 

 

 

 

 

 

 

 

DO NOT DISTRIBUTE – CLOSE HOLD 

• 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 

• 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, but will be encouraged to provide 

substitute data in Column D. 

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 SAMHSA defined measure for the domain listed. 

Column B: Question/Response 

• Source Survey Item: For Tables 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 letter A, Pre-populated 

data. 

Column D: Approved Substitute Data – Grantees for which there are no NSDUH, FARS, 

UCR and/or NCES data will be able to voluntarily enter data for the items in this column. 

Substitute data are not allowed for grantees with pre-populated data. 
 

DO NOT DISTRIBUTE – CLOSE HOLD 

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SUPTRS BG Table 21 – Substance Use Disorder Primary 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 2018-2019 

Ages 21+ - CY 2018-2019 

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 2018-2019 

Ages 18+ - CY 2018-2019 

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 

(cigars, smokeless tobacco, pipe tobacco). 

Ages 12–17 - CY 2018-2019 

Ages 18+ - CY 2018-2019 

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 2018-2019 

Ages 18+ - CY 2018-2019 

5. 30-day Use

of Illicit 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, 

hallucinogens, inhalants, methamphetamine, and misuse of prescription 

drugs). 

Ages 12–17 - CY 2018-2019 

Ages 18+ - CY 2018-2019 

† 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. 
 

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SUPTRS BG Table 22 – Substance Use Disorder Primary 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 2018-2019 

Ages 21+ - CY 2018-2019 

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 2018-2019 

Ages 18+ - CY 2018-2019 

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 2018-2019 

Ages 18+ - CY 2018-2019 

SUPTRS BG Table 23 – Substance Use Disorder Primary 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 2018-2019 

Ages 21+ - CY 2018-2019 

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 2018-2019 

Ages 18+ - CY 2018-2019 

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. 
 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

A. 

Measure 

B. 

Question/Response 

C.

Prepopulated 

Data

D. 

Supplemental 

Data if any 

Ages 12–17 - CY 2018-2019 

Ages 18+ CY 2018-2019 

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 2018-2019 

Ages 18+ - CY 2018-2019 

5. Age at First

Use of Heroin 

Source Survey Item: NSDUH Questionnaire: “How old were you the 

first time you used heroin?” [Response option: Write in age at first use.] 

Outcome Reported: Average age at first use of heroin. 

Ages 12–17 - CY 2018-2019 

Ages 18+ - CY 2018-2019 

6. Age at First

Misuse of 

Prescription Pain 

Relievers Among 

Past Year 

Initiates 

Source Survey Item: NSDUH Questionnaire: “How old were you the 

first time you used [specific pain reliever]

‡ in a way a doctor did not 

direct you to use it?” [Response option: Write in age at first use.] 

Outcome Reported: Average age at first misuse of prescription pain 

relievers among those who first misused prescription pain relievers in 

the last 12 months. 

Ages 12–17 - CY 2018-2019 

Ages 18+ - CY 2018-2019 

† 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. 

SUPTRS BG Table 24 – Substance Use Disorder Primary 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 2018-2019 

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 2018-2019 

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 2018-2019 
 

-

 

 

 

 

 

 

 

-

 

 

 

 

 

 

-

A. 

Measure 

B. 

Question/Response 

C.

Prepopulated 

Data

D. 

Supplemental 

Data if any 

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 2018-2019 

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 2018-2019 

Substance Use Block Grant Table 25 – Substance Use Disorder Prevention NOMs Domain: 

Reduced Morbidity – Abstinence from Drug Use/Alcohol Use 

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 2018-2019 

Ages 18+ - CY 2018-2019 

SUPTRS BG Table 26 – Substance Use Disorder Primary Prevention NOMs Domain: 

Reduced Morbidity – Abstinence from Drug Use/Alcohol Use 

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 2019 
 

 

-

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPTRS BG Table 27 – Substance Use Disorder Primary Prevention NOMs Domain: Crime 

and Criminal Justice 

Measure: Alcohol Related 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 2019 

SUPTRS BG Table 28 – Substance Use Disorder Primary 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 2019 

SUPTRS BG Table 29 – Substance Use Disorder Primary 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 2018-2019 

2. Family

Communications 

Around Drug and 

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 
 

 

 

 

 

 

-

 

 

 

 

 

 

A. 

Measure 

B. 

Question/Response 

C. 

Prepopulated 

Data 

D. 

Supplemental 

Data if any 

Alcohol Use 

(Parents of children 

aged 12–17) 

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 2018-2019 

† 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. 

SUPTRS BG Table 30 – Substance Use Disorder Primary Prevention NOMs Domain: 

Retention 

Measure: Percentage of Youth Seeing, 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 2018-2019 

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

specific context 

SUPTRS BG Tables 31-35 – Reporting Period 

Start and End Dates for Information Reported on SUPTRS BG 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 SUPTRS BG 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 SUPTRS BG 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 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 

SUPTRS BG Tables 31, 32, 33, 34 and 35 

Please indicate the reporting period for each of the following NOMS. 

Tables A. Reporting Period 

Start Date 

B. Reporting Period 

End Date 

1. SUPTRS BG Table 31

Individual-Based Programs and Strategies –

Number of Persons Served by Age, Gender, Race, 

and Ethnicity

mm/dd/yyyy mm/dd/yyyy 

2. SUPTRS BG Table 32

Population-Based Programs and Strategies –

Number of Persons Served by Age, Gender, Race, 

and Ethnicity

mm/dd/yyyy mm/dd/yyyy 

3. SUPTRS BG Table 33 (Optional) 

Number of Persons Served by Type of

Intervention

mm/dd/yyyy mm/dd/yyyy 

4. SUPTRS BG Table 34

Number of Evidence-Based Programs and

Strategies by Type of Intervention

mm/dd/yyyy mm/dd/yyyy 

5. SUPTRS BG Table 35

Total Number of Evidence-Based Programs and

Total SUPTRS BG Dollars Spent on EvidenceBased Programs/Strategies

mm/dd/yyyy mm/dd/yyyy 

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. 

SUPTRS BG Table 31 – Substance Use Disorder Primary Prevention Individual-Based 

Programs and Strategies – Number of Persons Served by Age, Gender, Race, and Ethnicity 

Category Total 

A. Age 

0–5 
 

6–12 

13–17 

18–20 

21–24 

25–44 

45–64 

65–74 

75 and Over 

Age Not Known 

B. Gender 

Male 

Female 

Trans man 

Trans woman 

Gender non-conforming 

Other 

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 

More Than One Race (not OMB required) 

Race Not Known or Other (not OMB required) 
 

- -

- -

 

 

SUPTRS BG Table 32 – Substance Use Disorder Primary Prevention Population-Based 

Programs and Strategies – Number of Persons Served by Age, Gender, Race, and Ethnicity 

Category Total 

A. Age 

0–5 

6–12 

13–17 

18–20 

21–24 

25–44 

45–64 

65–74 

75 and Over 

Age Not Known 

B. Gender 

Male 

Female 

Trans man 

Trans woman 

Gender non-conforming 

Other 

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 

SUPTRS BG Table 33 (Optional) – Substance Use Disorder Primary 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 
 

 

 

SUPTRS BG Table 34 – Substance Use Disorder Primary Prevention 

Evidence-Based Programs and Strategies by Type of Intervention 

Definition of Evidence-Based Programs and Strategies: The guidance document for the 

Strategic Prevention Framework State Incentive Grant, Identifying and Selection Evidence-based 

Interventions, provides the following definition for evidence-based programs: 

• Inclusion in a Federal List or Registry of evidence-based interventions

• Being Reported (with positive effects) in a peer-reviewed journal

• Documentation of effectiveness based on the following guidelines:

o Guideline 1: The intervention is based on a theory of change that is documented

in a clear logic or conceptual model; and

o Guideline 2: The intervention is similar in content and structure to interventions

that appear in registries and/or the peer-reviewed literature; and

o Guideline 3: The intervention is supported by documentation that it has been

effectively implemented in the past, and multiple times, in a manner attentive to

Identifying and Selecting Evidence-Based Interventions scientific standards of

evidence and with results that show a consistent pattern of credible and positive

effects; and

o Guideline 4: The intervention is reviewed and deemed appropriate by a panel of

informed prevention experts that includes: well-qualified prevention researchers

who are experienced in evaluating prevention interventions similar to those under

review; local prevention practitioners; and key community leaders as appropriate,

e.g., officials from law enforcement and education sectors or elders within

indigenous cultures. 

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?
 

 

 

 

 

 

 

-

-

SUPTRS BG Table 34 – Substance Use Disorder Primary Prevention Number of EvidenceBased 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 

SUPTRS BG Table 35 – Total Substance Use Disorder Primary Prevention Number of 

Evidence Based Programs/Strategies and Total SUPTRS BG Dollars Spent on Substance Use 

Disorder Primary Prevention Evidence-Based Programs/Strategies 

Total Number of Evidence-Based 

Programs/Strategies for IOM Category below:

Total Substance Use Block Grant $Dollars Spent 

on evidence-based Programs/Strategies 

Universal Direct Total # $ 

Universal Indirect Total # $ 

Selective Total # $ 

Indicated Total # $ 

Unspecified Total# $ 

Total EBPs: Total Dollars Spent: $