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pdfDocument A.1
State/Tribal PSI
OMB No. 0930-0286
Expiration Date: 05/31/10
Public Burden Statement: 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 0930-0286. Public
reporting burden for this collection of information is estimated to average .75 hours per
client 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.
Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS) State/Tribal Youth
Suicide Prevention and Early Intervention Program
Prevention Strategies Inventory
(State/Tribal Version)
Instructions for the respondent: Thank you for taking the time to complete this
inventory. The Prevention Strategies Inventory (PSI) is designed to catalogue: (1) the
prevention strategies being developed and implemented and (2) the percent of GLS funds
expended to date by prevention strategy category. Some of the activities, products and
services that you are implementing locally are pre-established in the field of suicide
prevention and others are products and services that you are developing for local use –
this inventory will catalogue information about both. This administration of the
inventory will ask you to think back over the first two quarters of your grant funding;
subsequent administrations will be quarterly and will ask that you provide information
about the preceding quarter.
Before beginning the online inventory, please read carefully the following consent form
and click the “I CONSENT” button at the end to indicate that you agree to participate in
this data collection effort. It is very important that you understand that your participation
in this inventory is voluntary and that the information you share is private. This inventory
will take approximately 45 minutes.
As part of the cross-site evaluation of the Garrett Lee Smith (GLS) Memorial Suicide
Prevention Program through funding from SAMHSA, we are asking that you complete
this inventory of prevention strategies. The Prevention Strategies Inventory (PSI) is
designed to catalogue on a quarterly basis: (1) the prevention strategies being developed
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and implemented and (2) the percent of GLS funds expended to date by prevention
strategy category. Your consent requires that you read and agree to the following:
Privacy: The information that you provide via this online inventory will be kept private
except as otherwise required by law. No identifying information is requested as part of
the inventory. The information that we report to SAMHSA will not contain any
identifying information and your name will not be used in any reports about this
evaluation.
Risks: Completion of this inventory poses few, if any, risks to you. You may choose to
cease input of information at any time or not answer a question, for whatever reason.
Your participation is voluntary. Refusal to participate involves no penalty or adverse
consequences. If you consent to complete the inventory here are some additional things
you should know:
•
•
•
•
•
You may stop your input of data at any time without penalty or consequence.
You may chose to not answer a question at any time without penalty or
consequence.
You may contact the cross-site evaluation Project Director or Database
Administrator with any questions that you have about the evaluation and/or
the Prevention Strategies Inventory before, during or after you have
completed the inventory.
We encourage you to print a copy of this consent for your records.
Again, your name will not be used in any reports about this inventory.
Contact information: If you have any concerns about your participation in this study or
have any questions about the evaluation, please contact Christine Walrath, Principal
Investigator at Christine.M.Walrath-Greene@macrointernational.com or at 212-9415555. Please click the “I CONSENT” box below to proceed to the Prevention Strategies
Inventory.
“I CONSENT” (Move to next web page to start the inventory)
“I DO NOT CONSENT” (Move to the web page which should say “Thank
you for considering participation in collection of data through the
Prevention Strategies Inventory. Please contact Christine Walrath,
Principal
Investigator
at
Christine.M.WalrathGreene@macrointernational.com or at 212-941-5555 with any questions.”
and offer them an opportunity to go to the inventory’s Homepage.
Thank you!
The Prevention Strategies Inventory is organized as follows.
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Part A: Suicide Prevention Program Strategies: This section will ask you to select
the prevention strategies that are being developed and implemented in your
suicide prevention program.
Part B: Follow Up Questions on Selected Strategies: For each of the prevention
strategies you selected in Part 1, you will be asked follow up questions.
Part C: Budget: This section will ask for the amount of the total GLS budget
expended to date and the percent of funds expended to date by prevention strategy
category.
If at any time while you are working to complete this inventory you need to save your
entry and come back to it at a later time (before submitting as final), you can do so by
clicking the “NEXT PAGE” button in order to save your responses. You can then close
the survey webpage.
If you have questions or need help related to entering information, please send an email
to GLS-PSI@macrointernational.com for assistance. To begin the inventory, enter
your login name and password below. If you do not remember your login name and/or
password please refer to the email sent to you by ICF Macro about completing the
Prevention Strategies Inventory.
Login Name: _______________________
Password:________________________
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NOTE: BASELINE AND FOLLOW UP VERSIONS ARE IDENTICAL. FOLLOW UP
VERSION WILL BE PRE-POPULATED WITH INFORMATION FROM PREVIOUS
ADMINISTRATION.
SECTIONS:
A.
B.
SUICIDE PREVENTION PROGRAM STRATEGIES
FOLLOW UP QUESTIONS ON SELECTED STRATEGIES
1. OUTREACH AND AWARENESS
1.1.
Public Awareness Campaigns
1.2.
Outreach and Awareness Activities and Events
1.3.
Outreach and Awareness Products
2. GATEKEEPER TRAINING
2.1.
School-based Adult Gatekeeper Training
2.2.
School-based Peer Gatekeeper Training
2.3. Community-based Adult Gatekeeper Training
2.4. Community-based Peer Gatekeeper Training
3. ASSESSMENT AND REFERRAL TRAINING FOR MENTAL HEALTH
PROFESSIONALS AND HOTLINE STAFF
3.1.
Assessment and Referral Training for Mental Health Professionals
3.2.
Assessment and Referral Training for Hotline Staff
4. LIFESKILLS DEVELOPMENT
4.1.
Lifeskills development for youth curricula
4.2.
Cultural activities intended to build lifeskills, cultural identity and
community connectedness
5. SCREENING PROGRAMS
6. HOTLINES AND HELPLINES
7. MEANS RESTRICTION
7.1.
Public Awareness Campaigns
7.2.
Distribution of gun locks and lock boxes
7.3.
Outreach & Awareness Events
7.4.
Outreach & Awareness Products
8. POLICIES AND PROTOCOLS FOR INTERVENTION AND POSTVENTION
8.1.
Policies and protocols related to intervention
8.2.
Policies and protocols related to postvention
9. COALITIONS AND PARTNERSHIPS
9.1.
Leading or substantially supporting a Suicide Prevention Coalition
9.2.
Participating in coalitions related to youth prevention
9.3.
Partnerships with agencies and organizations
10. DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES
10.1. Mental-health related services
10.2. Postvention services
10.3. Case Management services
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C.
10.4. Crisis Response services
10.5. Traditional healing practices
BUDGET
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A.
SUICIDE PREVENTION PROGRAM STRATEGIES
1. What types of suicide prevention strategies are being implemented under your
GLS program? Select all that apply.
OUTREACH AND AWARENESS
Public Awareness Campaigns
[A Public Awareness Campaigns is an organized systematic effort through
various communications media to make the general public or particular
target populations aware of key messages in suicide prevention. Examples
of Public Awareness Campaign are: "Suicide Shouldn't Be A Secret",
“Ask, Listen and Refer” Campaign, "Don't Erase Your Future" campaign
etc.,]
Outreach and Awareness Activities/Events
[These are activities and events intended to promote awareness about
suicide prevention and are not connected to a particular public awareness
campaign. Examples of these types of activities are: a suicide prevention
poster contest, out of darkness walk or booth at a health fair and events
held during National Red Ribbon Week.]
Outreach and Awareness Products
[These are products intended to promote awareness about suicide
prevention. Their distribution is not limited to or connected to a particular
public awareness campaign or to a particular activity/event. Examples of
these types of products are: radio and TV Public Service Announcements,
website development or enhancement, newspaper articles, billboards and
awareness products such as stress balls, mood pens, T-shirts and
bracelets.]
GATEKEEPER TRAINING
School-based Gatekeeper Training
o School-based adult gatekeeper training
o School-based peer gatekeeper training
[School-based gatekeeper training programs are trainings designed to help
school staff identify students at risk of suicide and to refer them for help.
School adult gatekeepers may include any adult in the school (e.g.,
counselors, teachers, coaches, administrators or cafeteria staff and other
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school-based staff and volunteers) in a position to observe and interact
with students. Example: ASIST training for teachers.
School-based peer gatekeeper training programs are trainings designed to
help students identify peers at risk of suicide and refer them for help.
These programs may be targeted to all students in middle school or high
school or a particular grade. Some programs may also be targeted towards
selected “peer helpers”, who are usually selected through a process (by
self, peers, teachers, counselors etc,). Examples of programs to be
included here are: Signs of Suicide (SOS), Lifelines, natural helpers
program etc,]
Community Gatekeeper Training
o Community Adult Gatekeeper training
o Community Peer Gatekeeper training
[Community adult gatekeeper training programs are intended to train adult
community members to identify young people at risk of suicidal behaviors
and to refer them to appropriate sources of help. This "gatekeeping"
function can be undertaken by anyone who has significant contact with
youth in the course of professional or volunteer activities. Examples of
gatekeepers include coaches, clergy, police officers, health care
professionals, emergency medical services personnel, hairdressers and
barbers, nurses, primary care physicians and other traditional caregivers.
Example: QPR training for police officers.
Peer gatekeeper training programs are intended to train youth to become
“helpers” for other youth within their own peer groups. They are trained to
identify peers at risk of suicidal behaviors and refer them to appropriate
sources of help. Any youth may function as a peer gatekeeper - tribal
youth council members, natural helpers or veterans. Please note that if you
are training youth in a school setting, select “School-based peer
gatekeeper training”. If you are training youth in non-school settings,
select “Community Peer Gatekeeper training”.]
ASSESSMENT AND REFERRAL TRAINING FOR MENTAL HEALTH
PROFESSIONALS AND HOTLINE STAFF
Assessment and referral training for mental health professionals
[This category refers to training mental health professionals on assessing
and managing suicide risk and making appropriate referrals. Example:
Assessing and Managing Suicide Risk (AMSR) and training clinicians in
suicide risk assessment.]
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Assessment and referral training for hotline staff
[This category refers to training hotline staff in suicide risk assessment
and referral skills.]
LIFESKILLS DEVELOPMENT
Lifeskills development for youth curricula
[This category refers to curricula that aim to teach children and
adolescents the social competencies and life skills needed to support
positive social, emotional, and academic development. These life skills
include communication, problem solving, depression and stress
management, anger regulation, and goal setting. For example, the
American Indian Lifeskills Development Curriculum covers the following
topics: building self-esteem; identifying feelings, emotions, and life
stressors; developing effective communication and problem-solving skills;
recognizing and eliminating self-destructive behavior; exploring reasons
why people attempt suicide; identifying ways to help friends who are
considering suicide; and planning for the future.]
Cultural activities intended to build lifeskills, cultural identity and
community connectedness
[This category includes activities that use a “culture as prevention”
approach and are intended to strengthen the cultural identity of youth in
order to provide them with a feeling of security, a sense of belonging and
hope for the future. Examples of activities that would fall under this
category are: culture camps where youth learn about their traditions,
history and languages; recreational activities such as canoe trips, maze and
high rope; activities to teach youth traditional arts and crafts; youth
drumming and dancing events; and community events such as ceremonies
and feasts.]
SCREENING PROGRAMS
Early Identification Screening Programs
[Early identification Screening Programs involve the administration of a
screening instrument to identify at risk youth, such as TeenScreen.]
HOTLINES AND HELPLINES
Developing, maintaining or supporting crisis hotlines and helplines
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[This strategy refers to developing, maintaining or supporting hotline or
helpline services for the community. For example, a grantee may use GLS
funds to develop and maintain a hotline service for LGBT youth or a
grantee uses funds to develop a local call center for the National Suicide
Prevention Hotline. Please note that training for hotline staff should be
indicated under another category “Assessment and Referral Training for
Hotline Staff”.]
MEANS RESTRICTION
[This strategy refers to efforts to educate and encourage community members to
voluntarily keep firearms, medications and poisons safely away from youth. It
involves reducing access to firearms, drugs, pesticides, domestic gas, high places
and other methods of completing suicide. Examples of efforts that would be
reported under this category would be distribution of gun locks and lock boxes,
campaign dedicated to reducing access to lethal means, and outreach and
awareness events, activities and materials focused on access to lethal means.]
Public Awareness Campaigns
[A Public Awareness Campaigns is an organized systematic effort through
various communications media focused on creating awareness about
access to lethal means among the general public or particular target
populations. For example: “Lock 'Em Up” Prescription Drug Campaign.]
Distribution of gun locks and lock boxes
[This refers to distribution of gun locks, locks for gun cabinets and
lockboxes which can store items such as medicines, ammunition &
knives.]
Outreach & Awareness Events
[Outreach and awareness events or activities intended to promote
awareness about access to lethal means and not connected to a particular
public awareness campaign.]
Outreach & Awareness Products
[Outreach and awareness products intended to promote awareness about
access to lethal means and not connected to a particular public awareness
campaign. Examples of these types of products are: radio and TV Public
Service Announcements, website development or enhancement,
newspaper articles, brochures, billboards and awareness products such as
stress balls, mood pens, T-shirts and bracelets.]
POLICIES AND PROTOCOLS FOR INTERVENTION AND
POSTVENTION
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[Policies and protocols related to intervention guide the actions of all agencies
and staff involved in ensuring that at-risk youth receive coordinated, timely and
effective support (assessment, referral, treatment and follow-up). Policies and
protocols related to postvention guide the actions of all agencies and staff
involved in taking appropriate postvention steps to support family, friends and
other community members following a suicide and to prevent cluster suicides.
These policies and protocols may involve various agencies and services, including
mental health centers, hospitals, mobile crisis teams, police, schools etc., Polices
and protocols are formal written statements documenting the procedures to be
followed.]
Policies and protocols related to intervention
Policies and protocols related to postvention
COALITIONS AND PARTNERSHIPS
[Please indicate whether you are using GLS funds to: lead or substantially
support a suicide prevention coalition; participate in related youth prevention
coalitions such as youth substance abuse coalition; and partner with youth-serving
agencies and organizations.]
Leading or substantially supporting a Suicide Prevention Coalition
Participating in coalitions related to youth prevention
Partnerships with agencies and organizations
DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES
Mental-health related services
[Mental health–related services that are provided or supported by a grantee’s
suicide prevention program. Examples of potential mental health related services
are: Assessment services (e.g., a clinical assessment resulting from an early
identification activity or referral); Counseling services; and Family Support
services.]
Postvention services
[Services that are provided or supported by a grantee’s suicide prevention
program after a suicide attempt or a death by suicide, largely taking the form of
support for the bereaved (i.e., family, friends, professionals, and peers). Examples
of postvention services include: Family support services; Community support
services; Group or individual support services; and Peer support groups.]
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Case Management services
[Case management services that are provided or supported by a grantee’s suicide
prevention program. Services include assessing the needs of the at risk youth and
his or her family, and arranging, coordinating, monitoring, evaluating, and
advocating for a package of multiple services to meet the youth’s specific needs.]
Crisis Response services
[Emergency services such as crisis response services or mobile response services
provided or supported by a grantee’s suicide prevention program.]
Traditional healing practices
[This category refers to traditional healing practices grounded in Native history
and culture which help individuals move towards a state of mental well-being.
These may include practices such as sweat lodge ceremonies, talking circles in
response to a crisis, spiritual ceremonies and other cultural practices that support
healing and recovery.]
OTHER SUICIDE PREVENTION STRATEGIES
[Please report any other suicide prevention strategies that are not listed above.]
Other
Please specify: ____________
Other
Please specify: ____________
Other
Please specify: ____________
Other
Please specify: ____________
Subsequent sections will be restricted to the strategies that the respondent selected in Q1.
For each strategy, grantees can report multiple entries. For example, under “Public
Awareness Campaigns”, they can enter information about each campaign separately. Or
under “Policies and protocols related to intervention”, they can enter multiple protocols
separately.
SECTION B FOLLOW UP QUESTIONS ON SELECTED STRATEGIES
1. OUTREACH AND AWARENESS
1.1. Public Awareness Campaigns
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1. What is the name of the public awareness campaign?
__________________________________________________________________
2. Please describe the public awareness campaign – its goals, methods/elements and
intended audiences.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Please indicate the populations targeted by the public awareness campaign.
Youth/Students
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
4. Please indicate which of the following elements are used in this public awareness
campaign, and for each selected element, please provide a brief description.
Print materials such as brochures, posters & flyers
Please describe:
____________________________________________________________
____________________________________________________________
Print media such as newspapers/magazines/newsletters
Please describe:
____________________________________________________________
____________________________________________________________
Billboards
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Please describe:
____________________________________________________________
____________________________________________________________
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Please describe:
____________________________________________________________
____________________________________________________________
Website development/enhancement
Please describe:
____________________________________________________________
____________________________________________________________
Radio
Please describe:
____________________________________________________________
____________________________________________________________
TV
Please describe:
____________________________________________________________
____________________________________________________________
DVD
Please describe:
____________________________________________________________
____________________________________________________________
Events/activities
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Please describe:
____________________________________________________________
____________________________________________________________
Booth at health fair
Please describe:
____________________________________________________________
____________________________________________________________
Other
Please describe:
____________________________________________________________
____________________________________________________________
5. What methods are you using to evaluate the effectiveness of this public awareness
campaign?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
1.2. Outreach and Awareness Activities and Events
1. What is the name of activity/event?
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__________________________________________________________________
2. Type of activity/event
Booth at health fair
Out of darkness walk
Poster contest
Other events/activities Please enter type: __________________
3. Please describe the activity or event. Explain how the activity or event relates to
the goals of your suicide prevention program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the populations targeted by the activity or event.
Youth/Students
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
6. What methods are you using to evaluate the effectiveness of this activity or event?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
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Other Please specify: _______________
None, there are no plans to evaluate this product/service.
1.3. Outreach and Awareness Products
1. What is the name of product?
__________________________________________________________________
1. Type of product
Print materials such as brochures, posters & flyers
Print media such as newspapers/magazines/newsletters
Billboards
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Website development/enhancement
Radio
TV
DVD
Newspaper/magazine/newsletter
Other product Please describe: ___________________
2. Please describe the product. Explain how this product relates to the goals of your
suicide prevention program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Please indicate the populations targeted by the product.
Youth/Students
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
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7. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
2. SCHOOL GATEKEEPER TRAINING
2.1. School-based Adult Gatekeeper Training
1. What is the name of the training?
__________________________________________________________________
2. Please indicate the type of training:
QPR (Question, Persuade, Refer)
ASIST (Applied Suicide Intervention Skills Training)
SafeTALK
Frameworks
Other Please describe: __________________
Is this a locally developed training?
Yes
No
3. Please describe the training. If you are using a standard curriculum (one of the
types mentioned in Q2), you need not describe the content of the curriculum. If
you are using a locally developed curriculum, please describe the content of the
curriculum. Provide description such as why this particular training type has been
selected for these particular groups of trainees, how the training has been adapted
to meet the needs of this group of trainees, strategies for recruiting participants
etc,
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__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
Teacher
School Administrator
Mental health clinician/counselor/ psychologist
Social Worker/ Caseworker/Care coordinator
Emergency/crisis care worker
Administrative assistant/clerical support personnel
Academic advisor
Coach
Cafeteria staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
8. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
2.2. School-based Peer Gatekeeper Training
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1. What is the name of the training?
__________________________________________________________________
2. Please indicate the type of training:
Yellow Ribbon
Signs of Suicide (SOS)
Youth Depression & Suicide: Let’s Talk
Frameworks
Suicide 101
Lifelines
Sources of Strength
Other Please describe: __________________________
Is this a locally developed training?
Yes
No
3. Please describe the training. If you are using a standard curriculum (one of the
types mentioned in Q2), you need not describe the content of the curriculum. If
you are using a locally developed curriculum, please describe the content of the
curriculum. Provide description such as why this particular training type has been
selected for these particular groups of trainees, how the training has been adapted
to meet the needs of this group of trainees, strategies for recruiting participants
etc,
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
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All students
Selected peer “natural helpers”
Other Please specify: _______________
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
3. COMMUNITY GATEKEEPER TRAINING
3.1.
Community-based Adult Gatekeeper Training
1. What is the name of the training?
__________________________________________________________________
2. Please indicate the type of training:
QPR (Question, Persuade, Refer)
ASIST (Applied Suicide Intervention Skills Training)
Youth Depression & Suicide: Let’s Talk
SafeTALK
Suicide 101
Other Please describe: _______________________
Is this a locally developed training?
Yes
No
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3. Please describe the training. If you are using a standard curriculum (one of the
types mentioned in Q2), you need not describe the content of the curriculum. If
you are using a locally developed curriculum, please describe the content of the
curriculum. Provide description such as why this particular training type has been
selected for these particular groups of trainees, how the training has been adapted
to meet the needs of this group of trainees, strategies for recruiting participants
etc,
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
3.2. Community-based Peer Gatekeeper Training
1. What is the name of the training?
__________________________________________________________________
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2. Please indicate the type of training:
Yellow Ribbon
Signs of Suicide (SOS)
Youth Depression & Suicide: Let’s Talk
Frameworks
Suicide 101
Lifelines
Sources of Strength
Other Please describe: __________________________
Is this a locally developed training?
Yes
No
3. Please describe the training. If you are using a standard curriculum (one of the
types mentioned in Q2), you need not describe the content of the curriculum. If
you are using a locally developed curriculum, please describe the content of the
curriculum. Provide description such as why this particular training type has been
selected for these particular groups of trainees, how the training has been adapted
to meet the needs of this group of trainees, strategies for recruiting participants
etc,
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
5. What methods are you using to evaluate the effectiveness of this training?
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Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
4. ASSESSMENT AND CLINICAL TRAINING FOR MENTAL HEALTH
PROFESSIONALS AND HOTLINE STAFF
4.1. Assessment and Referral Training for Mental Health Professionals
1. What is the name of the training?
__________________________________________________________________
2. Please indicate the type of training:
AMSR (Assessing and Managing Suicide Risk)
RRSR (Recognizing and Responding to Suicide Risk)
Other Please describe: ____________________
Is this a locally developed training?
Yes
No
3. Please describe the training. If you are using a standard curriculum (one of the
types mentioned in Q2), you need not describe the content of the curriculum. If
you are using a locally developed curriculum, please describe the content of the
curriculum. Provide description such as why this particular training type has been
selected for these particular groups of trainees, how the training has been adapted
to meet the needs of this group of trainees, strategies for recruiting participants
etc,
23
Document A.1
State/Tribal PSI
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
Mental health clinician/counselor/ psychologist
Social Worker / Caseworker / Care coordinator
Other Please specify: ____________
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
4.2. Assessment and Referral Training for Hotline Staff
1. What is the name of the training?
__________________________________________________________________
2. Please indicate the type of training:
QPR (Question, Persuade, Refer)
ASIST (Applied Suicide Intervention Skills Training)
Youth Depression & Suicide: Let’s Talk
SafeTALK
Suicide 101
Other Please describe: _______________________
Is this a locally developed training?
Yes
24
Document A.1
State/Tribal PSI
No
3. Please describe the training. If you are using a standard curriculum (one of the
types mentioned in Q2), you need not describe the content of the curriculum. If
you are using a locally developed curriculum, please describe the content of the
curriculum. Provide description such as why this particular training type has been
selected for these particular groups of trainees, how the training has been adapted
to meet the needs of this group of trainees, strategies for recruiting participants
etc,
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
Mental health clinician/counselor/ psychologist
Social Worker / Caseworker / Care coordinator
Volunteers
Other Please specify: ____________
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
5. LIFESKILLS DEVELOPMENT
5.1. Lifeskills Development for Youth Curricula
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State/Tribal PSI
1. What is the name of the curriculum?
__________________________________________________________________
2. Type of curriculum
American Indian Life Skills Development Curriculum
Other Please describe: _____________
Is this a locally developed curriculum?
Yes
No
3. Please describe the curriculum. If you are using American Indian Life Skills
Development Curriculum (AILSDC), you need not describe the content of the
curriculum. For AILSDC, describe any adaptations for your target populations. If
you are using another type of curriculum, please describe the content of the
curriculum. For all curricula, provide description such as why this particular
curriculum has been selected, strategies for implementation and expected
outcomes.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please describe the youth who are being targeted (age group, demographics etc,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
5. What methods are you using to evaluate the effectiveness of this curriculum?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
26
Document A.1
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Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
5.2. Cultural activities intended to build lifeskills, cultural identity and
community connectedness
1. What is the name of the activity?
__________________________________________________________________
2. Type of activity
Culture camp
Canoe trips
Maze
High Rope
Traditional arts and crafts
Drumming event
Dancing event
Ceremonies
Other Please describe: ____________________
3. Please describe the activity.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please describe the youth who are being targeted (age group, demographics etc,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
5. What methods are you using to evaluate the effectiveness of this activity?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
27
Document A.1
State/Tribal PSI
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
6. SCREENING PROGRAMS
1. What is the name of the screening tool?
__________________________________________________________________
2. Please indicate the type of screening tool:
Suicide Risk Screening Tool
TeenScreen
SOS (Signs of Suicide)
Other tool Please specify: _____________
Other Screening Tool
Behavioral Health Screen - Primary Care
Diagnostic Predictive Scales (DPS)
Children's Depression Inventory (CDI)
Mood Disorder Questionnaire
Carroll-Davidson Generalized Anxiety Screening Tool
Pediatric Symptom Checklist - Youth Report
Depressive Symptom Inventory - Suicide Subscale Youth Report
Pediatric Health Questionnaire - 9M Depression Youth Report
Patient Health Questionnaire – 9 (PHQ)
Voice Diagnostic Interview Schedule for Children (Voice – DISC)
Youth Outcome Questionnaire (YOQ)
Universal Pre-screen (UPS)
Other tool Please specify: ___________________
3. Please describe the screening program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the settings targeted by the screening program.
School
Child Welfare
28
Document A.1
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Juvenile Justice
Physical Health
Mental Health Agency
Emergency Room
Other Please specify: ____________
5. What methods are you using to evaluate the effectiveness of this tool?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
7. HOTLINES AND HELPLINES
1. What is the name of the hotline/helpline?
__________________________________________________________________
2. Please describe the hotline/helpline.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Please indicate the populations targeted by the crisis hotline (geographic scope,
demographics etc,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. What methods are you using to evaluate the effectiveness of the crisis hotline?
Qualitative Methods
29
Document A.1
State/Tribal PSI
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
8. MEANS RESTRICTION
8.1.
Public Awareness Campaign
1. What is the name of the public awareness campaign?
__________________________________________________________________
2. Please describe the public awareness campaign – its goals, methods/elements and
intended audiences.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Please indicate the populations targeted by the public awareness campaign.
Youth/Students
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
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4. Please indicate which of the following elements are used in this public awareness
campaign, and for each selected element, please provide a brief description.
Print materials such as brochures, posters & flyers
Please describe:
____________________________________________________________
____________________________________________________________
Print media such as newspapers/magazines/newsletters
Please describe:
____________________________________________________________
____________________________________________________________
Billboards
Please describe:
____________________________________________________________
____________________________________________________________
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Please describe:
____________________________________________________________
____________________________________________________________
Website development/enhancement
Please describe:
____________________________________________________________
____________________________________________________________
Radio
Please describe:
____________________________________________________________
____________________________________________________________
TV
Please describe:
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Document A.1
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____________________________________________________________
____________________________________________________________
DVD
Please describe:
____________________________________________________________
____________________________________________________________
Events/activities
Please describe:
____________________________________________________________
____________________________________________________________
Booth at health fair
Please describe:
____________________________________________________________
____________________________________________________________
Other
Please describe:
____________________________________________________________
____________________________________________________________
5. What methods are you using to evaluate the effectiveness of this public awareness
campaign?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
32
Document A.1
State/Tribal PSI
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
8.2. Outreach and Awareness Activities and Events
1. What is the name of activity/event?
__________________________________________________________________
2. Type of activity/event
Booth at health fair
Out of darkness walk
Poster contest
Other events/activities
Please enter type: __________________
3. Please describe the activity or event.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the populations targeted by the activity or event.
Youth/Students
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
9. What methods are you using to evaluate the effectiveness of this activity or event?
33
Document A.1
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Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
8.3. Outreach and Awareness Products
1. What is the name of product?
__________________________________________________________________
2. Type of product
Print materials such as brochures, posters & flyers
Print media such as newspapers/magazines/newsletters
Billboards
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Website development/enhancement
Radio
TV
DVD
Newspaper/magazine/newsletter
Other product Please describe: ___________________
3. Please describe the product.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the populations targeted by the product.
34
Document A.1
State/Tribal PSI
Youth/Students
Parents/Guardians
Mental Health Professionals
Child Welfare Staff
Juvenile Justice Staff
Primary Care Staff
Education Staff
Other Please specify: ____________
Other Please specify: ____________
Other Please specify: ____________
5. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
9. POLICIES AND PROTOCOLS FOR INTERVENTION AND POSTVENTION
9.1. Policies and protocols related to intervention
1. What is the name of the policy/protocol?
__________________________________________________________________
2. Please provide a brief description of the policy or protocol (include elements such
as procedures for responding to youth at risk, types of agencies/staff involved in
the protocol and their respective roles and responsibilities, description of how the
protocol will be communicated, reviewed and evaluated etc.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
35
Document A.1
State/Tribal PSI
9.2. Policies and protocols related to postvention
1. What is the name of the policy/protocol?
__________________________________________________________________
2. Please provide a brief description of the policy or protocol (include elements such
as postvention procedures for responding to completed suicide, types of
agencies/staff involved in the protocol and their respective roles and
responsibilities, description of how the protocol will be communicated, reviewed
and evaluated etc.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
10. COALITIONS AND PARTNERSHIPS
10.1.
Leading or substantially supporting a suicide prevention coalition
1. What is the name of the coalition?
__________________________________________________________________
2. Please provide a brief description of the coalition (include elements such as such
as what types of agencies participate in the coalition, what are the goals of the
coalition, what are its major achievements and how frequently do the members
meet, strategies for sustaining the coalition etc.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10.2.
Participating in coalitions related to youth prevention
1. What is the name of the coalition?
__________________________________________________________________
36
Document A.1
State/Tribal PSI
2. Please provide a brief description of the coalition (include elements such as how
does your participation in this coalition advance your suicide prevention efforts,
what types of agencies participate in the coalition, what are the goals of the
coalition, what are its major achievements and how frequently do the members
meet, etc.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10.3.
Partnerships with agencies and organizations
1. Please provide a brief description of your efforts to build partnerships with youthserving agencies and organizations
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
11. DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES
11.1.
Mental Health Related Services
1. Type of service
Assessment services (e.g., a clinical assessment resulting from an
early identification activity or referral)
Counseling services
Family Support services
Other service Please describe: ___________________
2. Please provide a brief description of the service.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
37
Document A.1
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Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
11.2.
Postvention Services
1. Type of service:
__________________________________________________________________
2. Please provide a brief description of the service.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
11.3.
Case Management Services
1. Please provide a brief description of the service.
__________________________________________________________________
__________________________________________________________________
38
Document A.1
State/Tribal PSI
__________________________________________________________________
__________________________________________________________________
2. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
11.4.
Crisis Response Services
1. Please provide a brief description of the service.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
39
Document A.1
State/Tribal PSI
11.5.
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
Traditional Healing Practices
1. Please provide a brief description.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
OTHER SUICIDE PREVENTION STRATEGIES
1. Please provide a brief description of this suicide prevention strategy (include
elements such as type of strategy, target populations etc,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
40
Document A.1
State/Tribal PSI
Other Please specify: _______________
Quantitative Methods
Surveys
Assessments/Measures
Other Please specify: _______________
None, there are no plans to evaluate this product/service.
41
Document A.1
State/Tribal PSI
SECTION C BUDGET
1. How much of your GLS budget (including any matching funds) have you spent to
date? Specify dollar amount:
2. Please estimate the percentage of your total budget expended to date on the
following product/service categories.
OUTREACH AND AWARENESS
¾
¾
¾
Public Awareness Campaigns
Outreach and Awareness Activities and Events
Outreach and Awareness Products
GATEKEEPER TRAINING
¾
¾
¾
¾
School-based Adult Gatekeeper Training
School-based Peer Gatekeeper Training
Community-based Adult Gatekeeper Training
Community-based Peer Gatekeeper Training
___%
___%
___%
___%
___%
___%
___%
___%
___%
ASSESSMENT AND REFERRAL TRAINING FOR MENTAL HEALTH
PROFESSIONALS AND HOTLINE STAFF
___%
¾
¾
Assessment and Referral Training for Mental Health
Professionals
Assessment and Referral Training for Hotline Staff
LIFESKILLS DEVELOPMENT
¾
¾
Lifeskills development for youth curricula
Cultural activities intended to build lifeskills, cultural
identity and community connectedness
___%
___%
___%
___%
___%
SCREENING PROGRAMS
___%
HOTLINES AND HELPLINES
___%
MEANS RESTRICTION
___%
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Document A.1
State/Tribal PSI
¾
¾
¾
¾
Public Awareness Campaigns
Distribution of gun locks and lock boxes
Outreach & Awareness Events
Outreach & Awareness Products
___%
___%
___%
___%
POLICIES AND PROTOCOLS FOR INTERVENTION AND
POSTVENTION
___%
¾
¾
Policies and protocols related to intervention
Policies and protocols related to postvention
COALITIONS AND PARTNERSHIPS
___%
___%
___%
¾ Leading or substantially supporting a Suicide Prevention Coalition
¾ Participating in coalitions related to youth prevention
¾ Partnerships with agencies and organizations
___%
___%
___%
DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES
___%
¾
¾
¾
¾
¾
Mental-health related services
Postvention services
Case Management services
Crisis Response services
Traditional healing practices
OTHER SUICIDE PREVENTION STRATEGY
___%
___%
___%
___%
___%
___%
43
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.1
Data Elements for the Early Identification and Referral Follow-up Analysis
ariable Nam
uestion Numb
Question
Grantee
Grantee
U_ID
SubDate
eidate
efpid
efcase
efprovid
cs1
Survey Submission Date
Date of identification
cs2
Participant ID
cs3
cs3
efgate
cs3
efoth
efothd
cs3
cs3o
Sources of information used to
complete this form: Case record
review or existing data system
Directly from a provider (i.e., case
manager, clinician, mental health
professional)
Formats & Codes
Text
Randomly generated unique identifier
Text (System-generated date of submission
into the SPDC)
Text
Numeric (8)
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
Directly from a gatekeeper (i.e., not 0=Not Endorsed
a mental health professional)
1=Endorsed
0=Not Endorsed
Other
1=Endorsed
Other, please describe
Text
1= School
2 = Child Welfare
3 = Juvenile Justice
4 = Law Enforcement
5= Community‐based Organization
6= Physical Health
efsett
cs4
efsetto
cs4o
efsource
cs5
efsour_o
eirf1
cs6
1
Early Identification Activity Setting
Other Early Identification Activity
Setting
7= Mental Health Agency
8 = Home
9=Emergency
Room
10 = Other
Text
1=Screening
2= Parent / Foster Parent / Caregiver
3= Mental health service provider (e.g.,
clinician, school counselor, etc.)
4= Teacher or other school staff (including
college or university staff)
5=Child welfare staff
6= Probation officer or other juvenile justice
staff
7=Primary care provider (i.e., pediatrician)
8=Emergency room staff
9=Police
officer or other law enforcement staff
10=Peer
11=Other
Source of Early Identification of
Youth
Other Source of Early Identification
of Youth
Text
Youth Age
Numeric
Document F.1
Youth Gender
Other gender, specified
1 = Boy
2 = Girl
3= Transgender
4 = Other
Text
eirf2
eirf2o
2
2o
eirf3
3
eirf3a_1
3a
Is the youth of Hispanic or Latino
cultural/ethnic background?
Mexican, Mexican‐American, or
Chicano
eirf3a_2
3a
Puerto Rican
eirf3a_3
3a
Cuban
eirf3a_4
3a
Dominican
eirf3a_5
3a
Central American
eirf3a_6
3a
South American
eirf3a_7
eirf3ao
3a
3ao
Hispanic origin captured in local MIS 0=Not Endorsed
but not represented in list above
1=Endorsed
Text explanation for eirf3a_7
Text
eirf4_1
4
American Indian or Alaska Native
eirf4_2
4
Asian
eirf4_3
4
eirf4_4
4
Black or African American
Native Hawaiian or Other Pacific
Islander
eirf4_5
4
White
eirf4_6
eirf4o
4
4o
eirf5
5
eirf5a1
5a
eirf5a2
5a
Race captured in local MIS but not
represented in list above
Text explanation for eirf4_6
Was the youth referred for either
mental health or non-mental health
related services?
(if no to 5) why was the youth not
referred for any type of services? youth was already receiving mental
health services
(if no to 5) why was the youth not
referred for any type of services? No capacity at provider agencies to
make a mental health referral
1=No
2=Yes
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
Text
1=Yes
2=No
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.1
eirf5a3
eirf5a3o
5a
5a
eirf5a4
5a
eirf5a5
eirf5a5o
5a
5a
eirf6
6
(if no to 5) why was the youth not
referred for any type of services? youth already receiving other
supports
Description of other supports
(if no to 5) why was the youth not
referred for any type of services? youth was determined not to be at
risk during referral process
(if no to 5) why was the youth not
referred for any type of services? other
Other, please describe
eirf6a4
6a
eirf6a5
6a
Was the youth referred for nonmental health related services?
Type of non-mental health
recommendation: Informed youth of
crisis hotline
Type of non-mental health
recommendation: Discussed
availability of other supports with
youth
Type of non-mental health
recommendation: Tutoring /
academic counseling
Type of non-mental health
recommendation: Recreation /
afterschool activities
Type of non-mental health
recommendation: Primary Care or
Physical Health referral
eirf6a6
eirf6ao
6a
6ao
Other
Other, please describe
eirf6a1
eirf6a2
eirf6a3
6a
6a
6a
eirf7
7
eirf7m
7a
eirf7y
7a
eirf7b1
7b
eirf7b2
7b
eirf7b3
7b
was the youth referred for mental
health related services?
month of referral for mental health
related services
year of referral for mental health
related services
Where was the child referred for
mental health related services? Public Mental Health Agency or
Provider
Where was the child referred for
mental health related services? Private Mental Health Agency or
Provider
Where was the child referred for
mental health related services? Psychiatric Hospital / Unit
0=Not Endorsed
1=Endorsed
Text
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
Text
1=Yes
2=No
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
Text
1=Yes
2=No
Numeric (2)
Numeric (4)
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.1
eirf7b4
eirf7b5
eirf7b6
7b
7b
7b
eirf7b7
7b
eirf7b8
eirf7bo
7b
7b
eirf8
8
eirf8a
eirf8ao
8a
8ao
eirf9_1
9
eirf9_2
eirf9_3
eirf9_4
9
9
9
eirf9_5
9
eirf9_6
eirf9o
eirf10m
9
9o
10
Where was the child referred for
mental health related services? Emergency room
Where was the child referred for
mental health related services? Substance Abuse Treatment Center
Where was the child referred for
mental health related services? School Counselor
Where was the child referred for
mental health related services? Mobile Crisis Unit
Where was the child referred for
mental health related services? Other
Other, please describe
In the 3 months following the date of
referral, did the youth receive mental
health services as a result of the
mental health referral?
why did the youth not receive the
mental health service?
Other, please describe
What service did the youth receive
at the initial appointment? - Mental
Health assessment
What service did the youth receive
at the initial appointment? Substance use assessment
What service did the youth receive
at the initial appointment? - Mental
health counseling
What service did the youth receive
at the initial appointment? Substance abuse counseling
What service did the youth receive
at the initial appointment? - Inpatient
or residential psychological services
What service did the youth receive
at the initial appointment? - Other
service
Other, please describe
Date of initial service: Month
OMB No. 0930‐0286
Expiration Date: 05/31/10
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
Text
1=Yes
2=No
1=No action was taken following the referral
2=Made an appointment but youth did not
attend the appointment
3=Attempted to make an appointment but
youth was wait‐listed for at least 3 months
4=Parent refused or could not be contacted
5=Don't know
Text
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
0=Not Endorsed
1=Endorsed
Text
Numeric (2)
Document F.1
eirf10d
eirf10y
10
10
Date of initial service: Day
Date of initial service: Year
Numeric (2)
Numeric (4)
OMB No. 0930‐0286
Expiration Date: 05/31/10
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.2
Data Elements for the Early Identification and
Referral Follow-up Aggregate
Variable
Name
Question
Number
Question
Formats & Codes
Grantee
Text
SubDate
Survey Submission Date
Randomly generated unique identifier
Text (System-generated date of submission into
the SPDC)
efaname
efadate
Name of Grantee
Date
Text
Text
efatool
Type of screening tool
1 TeenScreen
2 Screening tool in SOS
3 Behavioral Health Screen—Primary Care
(BHS-PC)
4 Children's Depression Inventory (CDI)
5 DPS
6 HANDS
7 Mood Disorder Questionnaire
8 Carroll-Davidson Generalized Anxiety
Screening Tool
9 Pediatric Symptom Checklist - Youth Report
10 Depressive Symptom Inventory - Suicide
Subscale Youth Report
11 Pediatric Health Questionnaire—9M
Depression Youth Report
12 Patient Health Questionnaire—9 (PHQ)
13 T-ACE screening tool
14 Voice Diagnostic Interview Schedule for
Children (Voice—DISC)
15 Youth Outcome Questionnaire (YOQ)
16 Universal Pre-screen (UPS)
17 Other _______________________
efatool_oth
efavers
efasens
Other type of screening tool. Please
specify.
Version Used
Sensitivity Level Used
efawher
Where did the screening take place?
Grantee
U_ID
Text
Text
Text
1 School
2 Mental Health Facility
3 Child Welfare Agency
4 Juvenile Justice
5 Physical Health Agency or Primary Care
Practice
6 Community Based Organization
7 Law Enforcement Agency
8 Other (Please
explain________________________________
_______________)
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.2
Other, please explain
efawhero
Text
1=all youth in attendance 2=youth meeting a
particular criteria
efawho
efawhoo
efadistr
efasign
Who was screened
Eligibility criteria used
Number of consent forms distributed
Number of consent forms signed
efacount
efaposc
Unduplicated count of number screened Numeric
Unduplicated count of youth who scored
positive on the screening questionnaire
only
Numeric
efapos
efagen1
efagen2
efagen3
efagen4
efaoth
efagen5
1
1
1
1
1
1
Unduplicated count of number screened
positive 1) screen positive and deemed
at risk during interview 2) not screen
positive but deemed at risk during
interview 3) self identify
Gender: Female
Gender: Male
Gender: Transgender
Gender: Other
Gender other (specify)
Information on gender is missing
efarace1
efarace2
efarace3
2
2
2
efarace4
efarace5
2
2
efarace6
efarace7
2
2
efarace8
2
efarace9
2
efaace10
2
efaace11
efaace12
2
2
efaaceo1
efaace13
efaace14
2
2
2
Race: American Indian or Alaska Native
Race: Asian
Race: Black or African American
Race: Native Hawaiian or Other Pacific
Islander
Race: White
Race: American Indian or Alaska Native
and White
Race: Asian and White
Race: Black or African American and
White
Race: American Indian or Alaska Native
and Black or African American
Race: Native Hawaiian or Other Pacific
Islander and White
Race: Individuals reporting multiple
races not included above
Race: Information on race is missing
Race: Information on race is missing.
Please explain.
Ethnicity: Hispanic/Latino
Ethnicity: Non‐Hispanic/Latino
Text
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Text
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Text
Numeric
Numeric
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.2
efaace15
2
Ethnicity: Information on Hispanic
ethnicity is missing
Numeric
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.3
Data Elements for the Training Exit Survey Cover Page
Variable Name
Question Number
Grantee
Question
Text
Survey Submission Date
Randomly generated unique identifier
Text (System-generated date of submission into the
SPDC)
U_ID
SubDate
txsdate
1
txsid
2
txsnum
3
txsnum_under18
txsname
4
5
txsfac
6
txszip
6
txssch
7
txssch1
7
txssch2
7
txsjj
7
Formats & Codes
Grantee
Month/Day/Year
Text
Training ID. Sites belonging to
Cohorts 1, 2 or 3 have 5 digit
txsids, of which the first two digits
are the site ID. Sites belonging to
Cohort 4 have 6 digit txsids, of
which the first three digits are the
site ID.
Numeric
Number of Trainees who attended
the training
Numeric
Number of Trainees under 18
years of age who attended the
training
Name of Training
Text
Name of facility where training
was held
Text
Zipcode of facility where training
was held
Text
Agency/Organization Affiliation of 0=Not Endorsed
Trainees: School
1=Endorsed
How many schools are
represented at the training?
Numeric
How many of these schools have
participated in previous trainings? Numeric
Juvenile Justice/Probation
0=Not Endorsed
Office/Detention Centers
1=Endorsed
Document F.3
txsjj1
7
txsjj2
7
txscw
7
How many juvenile justice related
agencies/organizations are
represented at this training?
Numeric
How many of these have
participated in previous trainings? Numeric
0=Not Endorsed
Child welfare/foster care
1=Endorsed
txscw1
7
txscw2
7
How many child welfare related
agencies/organizations are
represented at this training?
How many have participated in
previous trainings?
txsmh
7
Mental Health Agency
txsmh1
7
txsmh2
7
txscbo
7
txscbo1
7
txscbo2
7
txsoth
txsotho
7
7
Numeric
Numeric
0=Not Endorsed
1=Endorsed
How many mental health related
agencies/organizations are
represented at this training?
Numeric
How many have participated in
previous trainings?
Numeric
0=Not Endorsed
Community‐based organization 1=Endorsed
How many community‐based
organizations are represented at
this training?
Numeric
How many have participated in
previous trainings?
Numeric
0=Not Endorsed
Other type of organization
1=Endorsed
Other, Please Specify
Text
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.3
txsoth1
7
txsoth2
7
OMB No. 0930‐0286
Expiration Date: 05/31/10
How many of these organizations
are represented at this training? Numeric
How many have participated in
previous trainings?
Numeric
txsnewtype
8
Type of Training (select one)
txsnewtype_oth
8
Other type of training (select one)
1=QPR (Question, Persuade, Refer)
2=Yellow Ribbon
3=ASIST (Applied Suicide Intervention Skills Training)
4=Signs of Suicide (SOS)
5=Youth Depression & Suicide: Let’s Talk
6=SafeTALK
7=Frameworks
8=Suicide 101
9=Lifelines
10=AMSR (Assessing and Managing Suicide Risk)
11=Teenscreen
12=Campus Connect
13=Other type of training
1=Gatekeeper training
2=Screener training
3=General awareness training
4=Clinical intervention/treatment training
5=Postvention training
8
9
9
Is this a train‐the‐trainer event?
Duration of Training: Hour
Duration of Training: Minutes
1 =Yes
2=No
Numeric
Numeric
txstot
txshr
txsmn
| File Type | application/pdf |
| File Title | PRODUCTS AND SERVICES INVENTORY |
| Author | Anupa |
| File Modified | 2010-05-19 |
| File Created | 2010-05-19 |