State of Illinois

Department of Human Services

Substance Abuse Prevention Program Request for Proposal – Page 1 of 3

Tables in Sub-Grants A, B and C

Table in Sub-Grants A, B and C

SCHOOL INFORMATION FORM
School Name / School Type
(Public or Private) / Community / Percent Low Income
and Source*
(public schools only) / Mobility Rate
and Source* (public schools only) / Enrollment by Grade Level: Grades 5-12 and Source* / Total Enrollment: Grades 5-12
North Middle School / Public / North City / 18%
School Report Card / 22%
School Report Card / 6- 220
7- 200
8- 195
Fall Housing Data / 615

Table in Sub-Grant B – Youth Prevention Education

Youth Prevention Education Implementation Table
School/Site / Population (Universal or Selected) / Grade Level Targeted / Estimated Number of Classes / Number of Sessions
per Class / Length of
Session (minimum 30 minutes) / Session Frequency
e.g., North Middle School / 6 / 8 / 11 / 60 minutes / 2x per week

State of Illinois

Department of Human Services

Substance Abuse Prevention Program Request for Proposal – Page 2 of 3

Table in Sub-Grant B – Parent/Family Education

Parent/Family Education Implementation Table
Site / Groups to be Served and Number per Group / Number of Sessions / Session Length (minutes) / Session Frequency
e.g., North Community Center / 4 groups/
12 per group / 8 / 60 minutes / Weekly

Table in Sub-Grant B – Communication Campaigns

Communication Campaign Planning and Implementation Table
School/Site / Grade or age levels / Type of campaign (norms or communication) / Proposed phase to begin (planning or implementation) / Implementation frequency

State of Illinois

Department of Human Services

Substance Abuse Prevention Program Request for Proposal – Page 3 of 3

Table in Sub-Grant B – Direct Service Grant Summary Table

DIRECT SERVICE GRANT
SUMMARY TABLE
Col 1 / Col 2 / Col 3 / Col 4 / Col 5 / Col 6 / Col 7
Direct Service Type / # of youth to be served / # of youth in geographic area / % of youth served (Col 2 /Col 3) / # of adults to be served / # of adults in geographic area / % of adults served (Col 5 / Col 6)
Youth Prevention Education
Parent/Family Education
Mentoring
Communication Campaigns
Optional Activities
Totals

Table in Sub-Grant B – Direct Service Grant Cost Per Participant – All Sites

DIRECT SERVICE GRANT
Cost Per Participant – All Sites
Col 1 / Col 2 / Col 3 / Col 4 / Col 5 / Col 6
Direct Service Type / # of youth to be served / # of adults to be served / Total amount of funds dedicated to approach / % of funds dedicated to approach / Cost per
participant
(Col 2 or 5/ Col 4)
Youth Prevention Education
Parent/Family Education
Mentoring
Communication Campaigns
Optional Activities
Totals