SPF PFS Application Form to Substitute Community-Level National Outcome Measures (NOMs) Data 1. Contact Information Name of the applicant (first and last name): Title: Mr. Ms. Dr. Other _____________________ PFS Position: Organization: Department: Mailing address: E-mail address: Telephone: Fax: Does this request apply to all PFS funded subrecipients? Yes (indicate the number of subrecipients that are requesting No this NOM substitution) _____________________ 2. Measure Labels and Reported Outcome Label of the NOM(s) indicator for which the grantee is requesting a substituted proxy measure (e.g., 30-day use of alcohol): wording of the proxy measure and response items the grantee is requesting to substitute for the NOM(s) for example, how many occasions (if any) have you had alcoholic beverages – “One (beer, wine or hard liquor) to drink more than just a few sips during the past 30 days: 0 – – occasions, 1 or 2 occasions, 3 to 5 occasions, 6 to 9 occasions, 10 to 19 occasions, 20 to 39 occasions.” Exact wording of the outcome that will be reported to SAMHSA/CSAP for example, – “Percent who reported having used alcohol during the past 30 days.”
SPF PFS Application Form to Substitute Community-Level National Outcome Measures (NOMs) Data 1. Contact Information Name of the applicant (first and last name): Title: Mr. Ms. Dr. Other _____________________ PFS Position: Organization: Department: Mailing address: E-mail address: Telephone: Fax: Does this request apply to all PFS funded subrecipients? Yes No (indicate the number of subrecipients that are requesting this NOM substitution) _____________________ 2. Measure Labels and Reported Outcome Label of the NOM(s) indicator for which the grantee is requesting a substituted proxy measure (e.g., 30-day use of alcohol): wording of the proxy measure and response items the grantee is requesting to substitute for the NOM(s) – for example, “One how many occasions (if any) have you had alcoholic beverages (beer, wine or hard liquor) to drink – more than just a few sips – during the past 30 days: 0 occasions, 1 or 2 occasions, 3 to 5 occasions, 6 to 9 occasions, 10 to 19 occasions, 20 to 39 occasions.” Exact wording of the outcome that will be reported to SAMHSA/CSAP – for example, “Percent who reported having used alcohol during the past 30 days.”
application_form_to_substitute_community_level_noms.docx