Levels 1, 2.1, and 2.5

Human Services Block Grant / Comparative Effectiveness Research (CER) Data Tracking

Information must be submitted for ALL Dauphin County residents, regardless of funding source. If you do not have any Dauphin County residents in treatment, you must enter zeros.

Person submitting form - Contact information

First Name

Last Name

Phone

Provider Name

Select Month

Select Year

For the chosen month, please enter the number of current and discharged individuals that had a treatment review approximately 60 days after his/her admission. This includes individuals in partial hospitalization, outpatient, and intensive outpatient services.

Number of current and discharged individuals (from entry made in previous box) that reported less frequency of use of the primary drug of choice in the 30 days prior to that review.

Check Yes if blood/urine test was done

For the chosen month, please enter the number of current and discharged individuals that had a treatment review, not to include his/her initial 60-day review. This includes individuals in partial hospitalization, outpatient, and intensive outpatient services.

Number of current and discharged individuals (from entry made in box above) who reported less frequency of use of his/her drug of choice in the 30 days prior to that review.

Check Yes if blood/urine test was done