Form SOR TOR Final Tool SOR TOR Final Tool SOR TOR Final Tool

Form Approved

OMB No. 0930-0384

Expiration Date: XX/XX/XXXX

Substance Abuse and Mental Health Services Administration (SAMHSA)

Center for Substance Abuse Treatment (CSAT)

State Opioid Response (SOR)/Tribal Opioid Response (TOR) – Program Instrument

Public reporting burden for this collection of information is estimated to average between 33 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (0930-0384); 5600 Fishers Lane, Rockville, MD 20857.An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0384.

1. PROGRAM SPECIFIC QUESTIONS

For all program-specific questions in this section, information is reported quarterly therefore consider the past three months as the reporting period. Information and data should be reported for all programs/services either funded wholly or in part by SOR/TOR grant funds.

Information is reported quarterly as follows:

Q1: October 1 - December 31; reporting due January 31

Q2: January 1 - March 31; reporting due April 30

Q3: April 1 - June 30; reporting due July 31

Q4: July 1 - September 30; reporting due October 31

1. How many kits of naloxone and other opioid overdose reversal medication has your state/territory/Tribal entity purchased since the last reporting period?

_____Naloxone nasal spray product (e.g., Narcan®, Kloxxado®, RiVive™, generic naloxone nasal spray)

_____Nalmefene (Opvee®) nasal spray

_____Naloxone liquid for intramuscular administration (e.g., generic naloxone single or multi-dose vials, Zimhi®)

_____other opioid overdose reversal medications (please specify) __________________________

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

2. How many kits of naloxone and other opioid overdose reversal medication has your state/territory/Tribal entity distributed since the last reporting period?

_____Naloxone nasal spray product (e.g., Narcan®, Kloxxado®, RiVive™, generic naloxone nasal spray)

_____Nalmefene (Opvee®) nasal spray

_____Naloxone liquid for intramuscular administration (e.g., generic naloxone single or multi-dose vials, Zimhi®)

_____other opioid overdose reversal medications (please specify) ___________________

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

3. Which entities did your state/territory/Tribal entity distribute naloxone and other opioid overdose reversal medication kits to since the last reporting period? (select all that apply)

☐ schools, colleges, and universities

☐ harm reduction organizations (e.g., syringe services programs)

☐ shelters or agencies that provide services to people experiencing homelessness

☐ faith-based organizations

☐ first responders (e.g., police departments, fire departments, and emergency medical services)

☐ criminal justice settings (e.g., courts, jails, prisons, probation, and parole)

☐ local health departments or county health departments

☐ community organizations that are not harm reduction organizations (e.g., veteran organizations, libraries)

☐ substance use disorder treatment facilities (e.g., SUD outpatient, Opioid Treatment Programs, and residential treatment facilities)

☐ mental health treatment facilities (e.g., certified community behavioral health clinics and other community mental health centers)

☐ recovery facilities (e.g., recovery community organizations, recovery housing, and sober living homes)

☐ community health centers or federally qualified health centers

☐ hospitals/emergency departments

☐ pharmacies

☐ Tribal government entities (e.g., education, human services, or public works department)

☐ Tribally-run businesses (e.g., casinos, hotels, and stores)

☐ commercial business entities (e.g., restaurants, construction companies, and retail business establishments)

☐ other types of entities (please specify) _________________________________________

☐ Check here if NO naloxone and other opioid overdose reversal medication kits were distributed since the last reporting period.

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

4. Of the naloxone and other opioid overdose reversal medication kits distributed, how many overdose reversals occurred in your state/territory/Tribal entity since the last reporting period?

_____overdoses reversed

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

5. How many drug checking technologies as directed by SAMHSA has your state/territory/Tribal entity purchased since the last reporting period?

_____Fentanyl test strips

_____Xylazine test strips

_____other drug checking technologies as directed by SAMHSA (please specify) _______________

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

6. How many drug checking technologies as directed by SAMHSA has your state/territory/Tribal entity distributed since the last reporting period?

_____Fentanyl test strips

_____Xylazine test strips

_____other drug checking technologies as directed by SAMHSA (please specify) _______________

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

7. How many first responders and individuals in key community sectors has your state/territory/Tribal entity trained on recognizing an opioid overdose and appropriate use of naloxone and other opioid overdose reversal medications since the last reporting period?

_______first responders (e.g., law enforcement, emergency medical services, and fire departments)

_______ individuals in key community sectors (e.g., family members, peers, military, criminal justice, community groups, and coalitions)

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

8. How many individuals in your state/territory/Tribal entity were educated on the consequences of opioid and/or stimulant misuse through the following activities since the last reporting period?

_____ individuals educated using strategic messaging (e.g., media campaigns, targeted social media content, and other similar strategies)

_____ individuals educated through prevention and education activities (e.g., implementation of evidence-based curriculum, training events, and youth-led activities)

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

9. How many individuals in your state/territory/Tribal entity were trained to provide school-based prevention and education activities to school-aged children since the last reporting period?

______individuals

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

10. How many school-aged children in your state/territory/Tribal entity received school-based prevention and education activities on the consequences of opioid and/or stimulant misuse since the last reporting period?

______school-aged children

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

1. How many unduplicated individuals received treatment services for opioid use disorder (OUD) since the last reporting period?

_______unduplicated individuals

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

2. Of the number of unduplicated individuals in question 11a, how many received the following medication for OUD (MOUD) since the last reporting period?

_______Methadone

_______Buprenorphine

_______Injectable Naltrexone

_______More than one MOUD

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

1. How many unduplicated individuals received treatment services for stimulant use disorder since the last reporting period?

_______unduplicated individuals

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why.

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

1. Of the number of unduplicated individuals in question 12a, how many received contingency management since the last reporting period?

_______ unduplicated individuals

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

1. How many unduplicated individuals received recovery support services since the last reporting period?

_______unduplicated individuals

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

2. Of the number of unduplicated individuals in question 13a, how many received the following recovery support services since the last reporting period?

_______Recovery Housing

_______Recovery Coaching or Peer Coaching

_______Employment Support

_______Other recovery support services (specify) _______________

☐ Check here if this information is unavailable

If reporting either a zero value or information is unavailable, please indicate why:

Activity is not part of our plans for this grant.

Activity is planned to begin at a later date.

Please specify planned start date ____________________

Activity is being funded by other funds (e.g., other non-SOR/TOR SAMHSA funds; State funds, and/or other federal funds (i.e., CDC grants, CMS (Medicare or Medicaid), etc.).

Partners have not provided any information about this item for this period.

Planned activity was completed/targets were met in a previous period.

Other (specify) ______________________________

2. SUB-RECIPIENT ENTITY INVENTORY

For the table below, please provide expenditure amounts, from the previous fiscal year, for each SOR/TOR grant sub-recipient. Also, check the boxes under each of the types of services, either funded wholly or in part by SOR/TOR grant funds, associated with those expenditures from the previous fiscal year. This information is reported annually, no later than 30 days after the end of the second quarter (i.e., April 30) of the budget period. If you do not have SOR/TOR grant sub-recipients, please check the box below the table.

14. Please provide the following: (1) a list of all SOR/TOR grant sub-recipients, (2) expenditure amounts for each grant sub-recipient, and (3) the types of services provided by each grant sub-recipient.

Types of Services (check all that apply)

Prevention

Harm Reduction

Treatment

Recovery Support Services

SOR/TOR Grant Sub-Recipient

Street Address

State

Zip Code

SOR/TOR Expenditure Amount

Training & Education

Strategic Messaging

School-based Interventions

Community-based Interventions

Overdose Reversal Medications

Drug Checking Technologies

MOUD

Residential Treatment

Outpatient Treatment

Contingency Management

Peer/ Recovery Coaching

Recovery Housing

Employment Support

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐ Check here if you do not have SOR/TOR grant sub-recipients.

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