approved tribal practices application form- oregon（批准部落实践申请表,俄勒冈州）（25页）.docVIP

PAGE Rev: 12 April 2010 Page PAGE \* MERGEFORMAT 1 Oregon Addictions Mental Health Division Evidence-Based Programs Tribal Practice Approval Form, Mk V Name of Tribal Practice Brief Description Other Examples of this Tribal Practice Evidence Basis for Validity of the Tribal Practice: Historical/Cultural Connections Longevity of the Practice in Indian Country Teachings on which Practice is based Values incorporated in Practice Principles incorporated in Practice Elder’s approval of Practice Community feedback/ evaluation of Practice Goal Addressed by this Tribal Practice Target Populations Institute of Medicine Strategy (check off one of the following four) “Universal” “Selective” “Indicated” Treatment Socio-demographic or other characteristics Rev: 12 April 2010 Page PAGE \* MERGEFORMAT 25 Age Sex Occupation Living Cond’ns Other Risk and Protective Factors Addressed Domain Risk Factors Protective Factors Community Family Peer School Individual Tribal Practice—Personnel Tribal Practice—Key Elements Tribal Practice—Materials Tribal Practice—Optional Elements Outcomes Decrease Increase Specify Avoidable death Longevity Disease-specific morbidity Health Disability Handicap Ability Pain and Suffering Wellbeing Alienation Anomy Isolation Social/Community/ Cultural Connectedness Abuse Dependency Addiction Abstinence Non-harmful Use Unemployment Employment Educational failure Educational Success Dysfunctional family Healthy Family Delinquency/crime Good Behavior Homelessness Instability Stable Housing Unhealthy Attitude, Beliefs, Ignorance, Lack of Skills, Lifestyle Healthy Attitudes, Beliefs, Skills, Lifestyle Contact person for Agency Providing the Tribal Practice Person Phone e-mail Practice Approval Date_ ___ FILENAME \p \* MERGEFORMAT X:\SOM\Psych\One Sky Center\Tribal Stakeholders Best Practices\Tribal Practice Description Mk V.docx Run: DATE