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38 <br /> EXHIBIT F TO NC MOA: <br /> IMPACT INFORMATION <br /> Within 90 days of the end of any fiscal year in which a Local Government expends Opioid <br /> Settlement Funds, the Local Government shall report impact information for each strategy that it <br /> funded with Opioid Settlement Funds during that fiscal year ("funded strategy"), using the <br /> STANDARD FORM or the SHORT FORM for each funded strategy. <br /> The STANDARD FORM is recommended to all Local Governments for all funded strategies. <br /> However, Local Governments may use the SHORT FORM as follows: <br /> • All Local Governments that receive less than 0.2 percent(two-tenths of one percent)of the <br /> total Local Government Allocation as shown on Exhibit G may use the SHORT FORM <br /> for all funded strategies. <br /> • All Local Governments that receive 0.2 percent (two-tenths of one percent) or more but <br /> less than 0.3 percent(three-tenths of one percent)of the total Local Government Allocation <br /> as shown on Exhibit G must use the STANDARD FORM for the funded strategy that <br /> received the largest amount of settlement funds during the fiscal year and may use the <br /> SHORT FORM for all other funded strategies. <br /> • All Local Governments that receive 0.3 percent (three-tenths of one percent) or more but <br /> less than 0.4 percent(four-tenths of one percent) of the total Local Government Allocation <br /> as shown on Exhibit G must use the STANDARD FORM for the two funded strategies <br /> that received the largest amount of settlement funds during the fiscal year and may use the <br /> SHORT FORM for all other funded strategies. <br /> STANDARD FORM <br /> 1. County or municipality and fiscal year covered by this report. <br /> 2. Name, title, and organization of person completing this report. <br /> 3. Name of funded strategy, letter and/or number of funded strategy on Exhibit A or Exhibit B <br /> to the MOA, and number and date of resolution(s) authorizing expenditure of settlement <br /> funds on funded strategy. <br /> 4. Brief progress report describing the funded strategy and progress made during the fiscal <br /> year. Recommended length: approximately one page (250 words). <br /> 5. Brief success story from a person who has benefitted from the strategy(de-identified unless <br /> the person has agreed in writing to be identified). Recommended length: approximately one <br /> page (250 words). <br /> 6. One or more process measures, addressing the question, "How much did you do?" <br /> Examples: number of persons enrolled, treated, or served; number of participants trained; <br /> units of naloxone or number of syringes distributed. <br /> 7. One or more quality measures, addressing the question, "How well did you do it?" <br /> Examples: percentage of clients referred to care or engaged in care; percentage of staff with <br /> Exhibits, page 20 <br />