Free AODA Program Performance Report - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20389 (Rev. 08/2008)

STATE OF WISCONSIN Wis. Stats. 46.973, 51.45(4)(i), & 51.42(3)(ar)(15)

AODA PROGRAM PERFORMANCE REPORT
Use of form: Substance abuse providers receiving grant awards from the Division of Mental Health and Substance Abuse Services are required to complete this form quarterly. Instructions: Instructions for completing this form are available from the Bureau of Prevention Treatment and Recovery. Mail to: Department of Health Services Division of Mental Health and Substance Abuse Services Bureau of Prevention Treatment and Recovery ATTN: Contract Administrator Box 7851, Madison, WI 53707-7851 Fax Number: (608) 266-1533 Report Period: January - March April - June July - September October - December A. PROJECT IDENTIFICATION INFORMATION Name - State Grant Program Name - Local Project Name - Agency Name - Project Contact B. WORK PLAN OR TIMETABLE PROGRESS NARRATIVE City Telephone Number Date - Report Submitted

1. Describe progress on project work plan or timetable; e.g., hiring staff, training / orientation, site development.

2. Describe general problems or delays the project is experiencing and plans or efforts undertaken to resolve them.

3. Describe identified project needs; e.g., set up formal client waiting list, technical assistance and / or training needs, budget revisions, no-cost extension, new or modified service component, etc.

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20389 (Rev. 08/2008)

STATE OF WISCONSIN

2

C. SERVICE UTILIZATION PROGRESS AND NARRATIVE

1. Describe whether quarterly plans were achieved with respect to target group and service area. Attach additional pages if needed. This Quarter Year-to-Date Service Target Group
Planned Actual Planned

Actual

2.

Describe how utilization was evaluated. If service usage levels were not achieved, describe the plans or efforts of corrective action which were undertaken to resolve them.

D. CLIENT OUTCOMES PROGRESS

1. List outcomes to evaluate program effectiveness.

2. Results for period.

3. How was the information used?

SIGNATURE - Agency / Program Authority

Date Signed