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pdfOMB No. 0930-xxxx
Expiration Date: xx/xx/xxxx
CALL LOG
The National Suicide Prevention Lifeline is asking participating crisis centers to complete Call Logs on as many Lifeline calls as
possible.
Step 1
Be sure that the call came in on one of the Lifeline lines.
Complete Section 1 only if all of the following are true:
You have given the caller appropriate referral and resource information,
The caller is stable enough to answer questions,
The call is about to end, and
In your opinion, asking the questions will probably not make the caller uncomfortable or upset or destabilize him/her.
Please remember that we rely on and respect your judgment as a trained crisis counselor.
Step 2
During or immediately after the call, complete Section 2 for all calls.
Section 1 (Ask caller these questions after reviewing instructions above)
“Before we end, I’d like to ask you some questions, if I may. Here at the National Suicide Prevention Lifeline we’re asking
callers a few simple questions. Your answers will help us better meet the needs of our callers. None of this information
will identify you in any way. Also, this is completely voluntary; in other words, whether you want to answer the questions
is up to you. Even if you decide not to answer the questions, you’re welcome to call us back any time you want.” Pause
for a moment in case the caller has a question. Then continue.
“Is it OK if I ask you the questions?” Pause for response from caller.
No. “That’s fine, thank you anyway. And thank you for calling the National Suicide
Prevention Lifeline. Is there anything else I can do for you today?”
Yes. “Thanks. OK, here’s the first question:”
Decided not to ask the above question because caller was not stable enough.
Caller does not have to answer every question. Check “No Answer” for any unanswered questions
1. “Which telephone number did you use to make this
call?” (If the caller doesn’t know, read the first two phone
numbers. Skip this question if a Spanish line was used.)
1-800-273-TALK (8255)
1-800-SUICIDE
2. “Would you mind telling me how old you are?” Pause for
caller’s response. Record response on Call Log and then say,
“OK, thank you.” Go to next question.
____ ____
Check here if caller prefers not to answer
Other
Don’t know
Check here if caller prefers not to answer
3. “How did you hear about this telephone number?” Pause for caller’s response(s). Record response(s) on Call Log and
then say, “OK, thank you.” Go to next question.
Bus/train/billboard
Phone Book
Health/Mental Health Professional
Print media (e.g. magazine, newspaper)
Religious leader
Friend/relative
Radio or TV
Other:
Internet
Don’t know (Go to #4)
Promotional materials (e.g. pens, magnets, brochures, posters, etc.) Check here if caller prefers not to answer.
4. “Have you ever served in the U.S. military?”
No
4A. (If yes, ask: “Are you currently in the military?”) Note:
“currently in the military” can mean that the caller is Active
Duty, in the National Guard, or in the Reserves.)
Yes
Check here if caller prefers not to answer.
No
“There are only a couple of more questions:”
Check here if caller prefers not to answer.
Yes
“There are only a couple of more questions:”
1 of 3
5. “Are you Hispanic or Latino?”
6. “Which of the following best describes you? You can
select more than one.” (Read the following list, pausing
briefly after each item to allow the caller to respond.)
Yes
No
American Indian or Alaska Native (If yes, please go to #7)
Check here if caller prefers not to answer
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Check here if caller prefers not to answer
7A. (Ask only if the person has indicated he/she is
American Indian or Alaska Native):
“You said you’re an American Indian/Alaskan Native. Are
you currently living on an Indian reservation?”
Yes
No
7B. (If the person indicates he/she does live on a tribal
reservation, then ask) “Would you mind telling me the name
of the reservation?”
_________________________________________________
Check here if caller prefers not to answer
Check here if caller prefers not to answer
Record response on Call Log and then say, “Thank you very much for answering these questions. And
thank you for calling the National Suicide Prevention Lifeline. Is there anything else I can do for you
today?”
Section 2 (Complete after hanging up, even if Section 1 is blank)
1. Date (MM/DD/YY)
___
___ / ___
2. Time (HH:00) (e.g. 02:00 or 10:00)
___ / ___
___
___
___ :
0
0
AM
PM
3. Call came in on one of the
Spanish lines
Yes
No
4. Gender
Male
Female
Unable to determine
5. Calling For
Friend
Self
Parent
Sibling
Patient
Son/daughter
Spouse/Significant Other
Other _________________________
6. What prompted call (select all that apply)
Abuse/Violence
Military-related issues
Death of a family member/friend
Physical illness
Disaster/post-disaster needs
Relationship problems with friends/partners
Specify disaster______________________________
Sexual orientation issues
Family problem with parents or children
Substance abuse/addiction
Financial problems
Suicide attempt in progress
Homelessness issues
Suicidal intent
Information/materials request
Suicidal thoughts
Loneliness
Other:
Mental illness/emotional problem
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7. Is the caller currently in mental health and/or
substance abuse treatment?
8. Has the caller ever attempted suicide?
Yes
Yes
No
No
Don’t know
If Yes: Once
More than once
Don’t know how many times
Don’t know
9. Please indicate the type of referrals given by
counselor to caller (please check all that apply)
10. Crisis/Emergency Intervention
Not needed
Current treatment providers
Outpatient/community mental health
Needed but unable to dispatch
Dispatched (if yes, please check one option below)
Crisis/mobile outreach
Crisis stabilization services
Detoxification/substance abuse treatment
Emergency room (self/family transport)
Peer run or peer support services
Crisis/mobile outreach
Law enforcement
Ambulance
Other
Other social service
Caller did not want referrals
11. Did the caller agree to a follow-up call by crisis center?
Yes
No
Not applicable
Note to the Crisis Counselor: Thank you for taking the time to gather this information. We will use it to track which
populations Lifeline is reaching and to report trends to all participating crisis centers. We also hope to use the
information to more effectively promote Lifeline to potential callers and to help us develop crisis counselor training
that will be helpful to you and your coworkers.
For hard copies only: Please give completed Call Logs to your supervisor.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx.
Public reporting burden for this collection of information is estimated to average 3 minutes per caller per year,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
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| File Type | application/pdf |
| File Title | National Suicide Prevention Lifeline |
| Author | lbernik |
| File Modified | 2009-02-24 |
| File Created | 2009-02-24 |