Download:
pdf |
pdfDocument B.2
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 10 minutes 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) Campus Suicide
Prevention Program
Training Exit Survey
Thank you for participating in this survey about the training you just attended as part of the
Garrett Lee Smith Campus Suicide Prevention Cross-site Evaluation. This survey asks questions
about the training you just completed, what you plan to do with what you learned, and your
satisfaction with the training. Findings from this survey will help inform the Substance Abuse
and Mental Health Services Administration (SAMHSA) about suicide prevention activities.
Before you complete this survey, please read this consent form. The survey will take
approximately 10 minutes. By completing and returning this survey, you are consenting to
participate. Your participation in this survey is completely voluntary; there are no right or
wrong answers; and you may ask any questions that you have before, during or after you
complete the survey.
Privacy: Your answers to the survey questions will be kept private except as otherwise required
by law. Your name will not be linked with the information on your survey. The information that
we report to SAMSHA will not contain your name. Your name will not be used in any reports
about this evaluation.
Procedures: All participants in training activities funded as part of your Campus Suicide
Prevention Program are being asked to complete this survey. Therefore, your participation is
very important. The survey questions will ask you about your participation in [INSERT
TRAINING NAME].
Risks: There are few, if any, risks to you by completing this survey. You may stop the survey at
any time or not answer a question. You will not be penalized for stopping. If you stop the
survey, at your request, we will destroy your survey. Any questions that you have about this
survey will be answered before you start the survey.
TRAINING ID: PARTICIPANT ID:
Contact information: If you have any concerns about completing this survey or have any
questions about the study, please contact Christine Walrath, Principal Investigator, at 212-9415555 or CWalrath@macrointernational.com.
In order to provide you with a copy of this consent form to take with you, please tear off
and keep the [color] copy, which is a copy of this consent form.
Thank you in advance for your willingness to participate.
Training Exit Survey
02.24.2010
Page 2
TRAINING ID: PARTICIPANT ID:
Thank you for your willingness to complete this survey. Your answers will help us
understand how trainings like the one you just completed can contribute to preventing
suicide among youth. Your answers are very important to us.
1.
Instructions: The main categories below represent different campus roles that you may identify with. Within each
primary role, is a list of secondary roles. Please FIRST select the primary role that best describes you, then
SECOND, within the primary role, please select the ONE ROLE best describes your role or affiliation at the
training.
For example, if you are a graduate student attending a training as part of your teaching assistant responsibilities, then
select “Student” as your primary role and within that role, you would select “Graduate teaching assistant”. If you
graduate student attending a training activity as a residential life advisor then select “Student” as your primary role
and within that role, you would select “Residential Life Advisor”.
Student
{ Disabled Student
{ Graduate teaching or research assistant
{ Intercollegiate Athlete
{ Mental Health/Psychology/Health Education
{
{
{
{
{
{
{
{
Concentration/Affiliation
Peer Counselor/Student Health worker
Researcher or program evaluator
Residential life advisor
Sorority/Fraternity Member
Student government/Organizations/Clubs
Teacher
Tutor/Learning Specialist
Veteran
Other Community Member
{ Community Group Member
{ Family Member/Caregiver
{ Relative
{ Volunteer (i.e. Big Brother/Big Sister, CASA, etc.)
{ Other - ___________________
Faculty/Instructor/Lecturer
{ Academic advisor
{ Administrative
{ Researcher or program evaluator
{ Researcher or program evaluator
{ Teaching
{ Tutor/Learning Specialist
Health Care Provider
{ Mental health or psychological counseling counselor
{ Other health professional
{ Primary care (e.g. physical/student health) provider
Staff
{ Administrative and Faculty Support Staff (e.g.,
{
{
{
{
{
{
{
academic affairs, finance, etc.)
Administrator (e.g., academic affairs, finance, etc.)
Athletic coach or trainer
Campus safety or other emergency response staff
Clergy/religious educator
Clerical/administrative support
Dean Provost
Facilities maintenance
Training Exit Survey
02.24.2010
Page 3
TRAINING ID: PARTICIPANT ID:
{ General Campus Support Staff (e.g., security,
nutrition, library)
{ Other Student Support Staff (e.g., registrar,
admissions, student life, etc.)
{ Residential life staff or advisor
{ Student Affairs
{ Tutor/Learning Specialist?
1. Please select the one primary role with which you most closely identify. For example, if you are a
faculty member who is also an administrator, choose the position that best matches your primary role
on campus. Were you required to participate in this training?
Yes
No
Don’t know
2. How do you intend to use what you learned during this training (select all that apply)?
Screen students for suicide behaviors (i.e., using a screening tool)
Publicize information about suicide prevention and mental health resources
Identify students who might be at risk for suicide
Provide direct services to students at risk for suicide and/or their families
Train others
Link students at risk of suicide with appropriate services or supports
Other (please describe:_______________________________)
Don’t intend to use what I learned
CURRENT CAMPUS…How do you intend to use what you learned during this training (select all
that apply)?
Screen youth for suicide behaviors (i.e., using a screening tool) (FROM S/T)
Formally publicize information about suicide prevention or mental health resources
Have informal conversations about suicide and suicide prevention with students and others
Identify students who might be at risk for suicide
Provide direct services to youth at risk for suicide and/or their families (FROM S/T)
Train other staff members
Make referrals to mental health services for at-risk students
Work with adult at-risk populations
Other (please describe:_______________________________)
Don’t intend to use what I learned
Please indicate your agreement with the following statements about the training.
1
Strongly
disagree
2
Disagree
3
Agree
4
Strongly
agree
3. The training increased my knowledge about suicide prevention.
4. The training materials I received (i.e. brochures, wallet cards,
etc.) will be very useful for my suicide prevention efforts.
5. The training met my needs.
6. The training addressed cultural differences in the students I
intend to serve (i.e., provided different cultural examples,
identified different cultures, etc.).
7. The training was practical to my life on campus.
8. I fully understand why I attended the training.
Training Exit Survey
01.16.2009
Page 4
5
N/A
TRAINING ID: PARTICIPANT ID:
9.
I am now more ready to help with suicide prevention on my
campus.
10. The things I learned will help prevent suicide or reduce the
problems that might lead to suicide (i.e., depression, substance
use, etc.).
On a typical day, about how much time do you spend interacting or talking directly with students?
0-15 minutes
15-30 minutes
30 minutes – 1 hour
1-2 hours
More than 2 hours
11.
How would you rate the training? (select one)
Below my skill level
At my skill level
Above my skill level
Don’t know
12. With whom do you expect to directly apply what you have learned during this training? (select all
that apply)
Students
Co-workers
Campus community members
Parents/foster parents/caregivers
Family/friends
Other (please describe: _____________________________)
*Participants will be asked to complete one of three training modules based on the type of
training they participated in (QPR/other brief gatekeeper training, AMSR/RRSR or Campus
Connect).
1. QPR AND OTHER BRIEF GATEKEEPER TRAININGS MODULE (also default
module for locally developed gatekeeper training if no local exit survey)
Now that you have received the QPR Gatekeeper training, please indicate how you would rate
your knowledge of suicide in the following areas?
16. Facts concerning Suicide Prevention:
Very Low
Low
Medium
High
Very High
17. Warning signs of suicide:
Training Exit Survey
01.16.2009
Page 5
TRAINING ID: PARTICIPANT ID:
Very Low
Low
Medium
High
Very High
18. How to ask someone about suicide:
Very Low
Low
Medium
High
Very High
19. Persuading someone to get help:
Very Low
Low
Medium
High
Very High
20. How to get help for someone:
Very Low
Low
Medium
High
Very High
21. Information about resources for help with suicide:
Very Low
Low
Medium
High
Very High
22. Please rate what you feel is the appropriateness of asking someone who may be at risk about
suicide.
Very Low
Low
Medium
High
Very High
23. What is the likelihood you will ask someone who appears to be at risk if they are
thinking of suicide?
Very Low
Low
Medium
Training Exit Survey
01.16.2009
Page 6
TRAINING ID: PARTICIPANT ID:
High
Very High
24. Please rate your level of understanding about suicide and suicide prevention.
Very Low
Low
Medium
High
Very High
This section contains a list of statements of what you may think or believe about suicide
prevention. Please read each statement and use the rating scale to indicate the degree to which
you agree or disagree with it. There are no right or wrong answers. It is important that you
answer all statements according to your beliefs and not what you think others may want you to
believe.
25. If someone I knew was showing signs of suicide, I would directly raise the question of
suicide with them.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
26. If a person's words and/or behavior suggest the possibility of suicide, I would ask the
person directly if he/she is thinking about suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
27. If someone told me they were thinking of suicide, I would intervene
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
28. I feel confident in my ability to help a suicidal person
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
29. I don't think I can prevent someone from suicide
Training Exit Survey
01.16.2009
Page 7
TRAINING ID: PARTICIPANT ID:
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
30. I don’t feel competent to help a person at risk of suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Training Exit Survey
01.16.2009
Page 8
TRAINING ID: PARTICIPANT ID:
2. AMSR AND RRSR MODULE (also default module for other clinical training if no
locally-developed exit survey)
Please rate the extent to which the workshop increased your knowledge in the following
areas:
1. Managing one’s own reactions to suicide.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
2. Reconciling the difference (and potential conflict) between the clinician’s goal to prevent
suicide and the client’s goal to eliminate psychological pain via suicidal behavior.
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
e.
3. Eliciting suicide ideation, behavior, plans and intent.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
4. Collaboratively developing a crisis response plan.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
5. Developing a written treatment and services plan that addresses the client’s immediate,
acute, and continuing suicide ideation and risk for suicide behaviors
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
6. Developing policies and procedures for following clients closely, including taking
reasonable steps to be proactive.
a.
b.
c.
d.
Training Exit Survey
01.16.2009
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
Page 9
TRAINING ID: PARTICIPANT ID:
Section II: Suicide Prevention Self-Efficacy
Formatted: French (France)
1) I am able to maintain a collaborative, non-adversarial stance by creating an atmosphere in
which the client feels safe in sharing information about suicidal thoughts, behaviors and
plans
Expert 10
9
8
7
6
5
4
3
2
1 Novice
2) I am able to demonstrate an understanding of suicide-related risk and protective factors by
asking questions about suicide-related risk and protective factors during assessment.
Expert
10
9
8
7
6
5
4
3
2
1 Novice
3) I am able to collect accurate assessment information about suicide-related risk by eliciting
risk and protective factors during the clinical interview and obtaining records and
information from collateral sources as appropriate.
Expert
10
9
8
7
6
5
4
3
2
1 Novice
3
2
1 Novice
4) I am able to identify warning signs of acute risk of suicide.
Expert 10
9
8
7
6
5
4
5) I am able to integrate a risk assessment for suicidality into a clinical interview
Expert 10
9
8
7
6
5
4
3
2
1 Novice
6) I am able to document assessment information from a bio-psycho-social and cultural
perspective
Expert 10
9
8
7
6
5
4
3
2
1 Novice
7) I am able to demonstrate an understanding of suicide-related risk and protective factors by
considering all relevant factors when formulating risk
Expert 10
9
8
7
6
5
4
3
2
1 Novice
8) I am able to collect accurate assessment information about suicide-related risk by eliciting
suicide ideation, behavior and plans and warning signs of acute risk
Training Exit Survey
01.16.2009
Page 10
TRAINING ID: PARTICIPANT ID:
Expert 10
9
8
7
6
5
4
3
2
1 Novice
9) I am able to make a clinical judgment of risk that a client will attempt or complete suicide in
the short and long term by working collaboratively with other professionals in an interdisciplinary team approach to integrate and prioritize all the information that has been
collected, including a consideration of developmental, cultural and gender-related issues
related to suicidality.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
10) I am able to document formulation of risk, including interaction with professional colleagues,
and write a sound rationale for clinical judgment.
Expert 10
Training Exit Survey
01.16.2009
9
8
7
6
5
4
3
2
1 Novice
Page 11
TRAINING ID: PARTICIPANT ID:
3. Campus Connect Module
Section I: Suicide Prevention Knowledge and Self-Efficacy
Not at all
True
1. I understand the meaning of
various suicide terms
(i.e., threat, attempt, survivor of
suicide).
Somewhat
True
Very
True
1
2
3
4
5 6
7
8
9
10
1
2
3
4
5 6
7
8
9
10
3. I am aware of the various
risk factors related to suicide.
1
2
3
4
5 6
7
8
9
10
4. I know how to ask someone
if they are thinking about suicide.
1
2
3
4
5 6
7
8
9
10
5. I understand the potential
impact of paraphrasing emotions.
1
2
3
4
5 6
7
8
9
10
6. I am familiar with the available
referral resources for emotionally
distressed students.
1
2
3
4
5 6
7
8
9
10
7. I feel comfortable asking
1
someone if they are thinking about suicide.
2
3
4
5 6
7
8
9
10
8.
1
2
3
4
5 6
7
8
9
10
9. I believe I am able to emotionally
connect with students in crisis.
1
2
3
4
5 6
7
8
9
10
10. I feel comfortable attempting to
emotionally connect with students
in crisis.
1
2
3
4
5 6
7
8
9
10
11. I feel capable of helping students in
1
2
3
4
5 6
7
8
9
10
2. I am familiar with the
prevalence rates of suicidal ideation
and suicide attempts among college
students.
I feel comfortable paraphrasing
emotions..
Training Exit Survey
01.16.2009
Page 12
TRAINING ID: PARTICIPANT ID:
crisis feel understood.
12. I feel able to assist emotionally
distressed students in accessing available
referral resources.
1
2
3
4
5 6
7
8
9
10
13. I believe that distressed students
will follow through with referrals I
provide to them.
1
2
3
4
5 6
7
8
9
10
Background Information
13.
14.
What is your gender?
Female
Male
Transgender
Other
What is your age? years
15. Are you Hispanic or Latino (select one)?
Yes
No
17a.
If Yes, Which group represents you? Are you… (select one or more)
Mexican, Mexican-American, or Chicano
Puerto Rican
Cuban
Dominican
Central American
South American
16. What is your race (select one or more)?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
This is the end of the survey.
Thank you for taking the time to complete this survey. Your participation is critical to the
success of the Garrett Lee Smith Memorial Suicide Prevention Cross-Site Evaluation.
Training Exit Survey
01.16.2009
Page 13
Document C.1
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 .25 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 and Campus Youth
Suicide Prevention and Early Intervention Programs
Training Utilization and Preservation - Survey
On [date of training] you participated in a training called [insert training name], as part of the
Garrett Lee Smith Memorial (GLS) State/Tribal and Campus Youth Suicide Prevention Program.
At the end of the program, you consented to be contacted for a follow up survey. We are
contacting you now to administer the survey. This survey asks questions about the training, what
you plan to do with what you learned during the training, and your satisfaction with the training.
Findings from this survey will help inform the Substance Abuse and Mental Health Services
Administration (SAMHSA) about suicide prevention activities.
The survey will take approximately 10 minutes. Your participation in this survey is
completely voluntary; and you may end the interview at any time. Your answers to the survey
questions will never be associated with your name or your organization You may ask any
questions that you have before, during or after you complete the survey. May we begin now?
Privacy: The information that we report to SAMSHA will not contain your name. Your name
will not be used in any reports about this evaluation.
Procedures: All participants in training activities funded as part of your State’s Youth Suicide
Prevention Program are being asked to complete this survey. Therefore, your participation is
very important. The survey questions will ask you about your participation in [INSERT
TRAINING NAME].
Risks: There are few, if any, risks to you by completing this survey. You may stop the survey at
any time or not answer a question. You will not be penalized for stopping. If you stop the
survey, at your request, we will destroy your survey. Any questions that you have about this
survey will be answered before you start the survey.
TRAINING ID: PARTICIPANT ID:
Contact information: If you have any concerns about completing this survey or have any
questions about the study, please contact Christine Walrath, Principal Investigator, at 212-941-5555 or
CWalrath@macrointernational.com.
Thank you in advance for your willingness to participate. This call may be recorded and/or
monitored for quality assurance purposes.
Training Exit Survey
03.02.2010
Page 2
TRAINING ID: PARTICIPANT ID:
Part I- Training Knowledge
1. Great, thanks, you participated in [insert training name] right?
[Insert Modules here*]
Part II- Self-efficacy
2. How well did [insert training name] prepare you to intervene with a youth aged 10 to 24
who may be at risk for suicide in your work, home, or community?
1
It did not prepare me at all
2
It prepared me somewhat
3
It prepared me very well
4
5
Not Applicable or No Opinion
3. Now that it has been about two months since your training, please describe how well you
think [insert training name] has helped in your work, home or community? [Interviewer
Instructions: if asked, the setting of interest is the one where they are most likely to use their
training] Please rate the following statements about [insert training name].
1-Strongly Disagree
2-Disagree
3- Agree 4- Strongly Agree 5-N/A
1 2 3 4 5
a. The training increased my knowledge about suicide prevention.
b. The training materials I received (i.e. brochures, wallet cards, etc.) have
been very useful for my suicide prevention efforts.
c. The training has met my suicide prevention needs.
d. The training addressed cultural differences in the youth I serve.
e. The training has proven practical to my work and/or my daily life.
f. I have used my training to help with youth suicide prevention in my
community.
g. The things I learned during the training have helped me prevent youth
suicide or reduce the problems that might lead to suicide (i.e., depression,
substance use, etc.).
4. Have you used your training to:
Screen youth for suicide behaviors (i.e., using a screening tool)
Formally publicize information about suicide prevention or mental health resources
Have informal conversations about suicide and suicide prevention with youth and others
Identify youth who might be at risk for suicide
Provide direct services to youth at risk for suicide and/or their families
Train other staff members
Make referrals to mental health services for at risk youth
Work with adult at-risk populations
Other (please describe:_______________________________)
Training Exit Survey
03.02.2010
Page 3
TRAINING ID: PARTICIPANT ID:
Don’t intend to use what I learned
[Insert Modules here*]
Part III- Post-Training Behavior
5. Have you used your training to train adults to intervene with a youth at risk for suicide?
[If Yes] About how many? [1-5; 6-10; 11-20; >20]
a. Have you used your training to train youth to intervene with a peer at risk for suicide
suicide?
[If Yes] About how many? [1-5; 6-10; 11-20; >20]
6.
Have you used [training name] to identify youth you thought might be at risk for suicide?
[Interviewer Instructions: if asked, this should be based on what they learned during their
training; if asked, youth are 10-24 years-old] [If No, skip to question 13]
a. [If Yes] About how many youth? [1-5; 6-10; 11-20; >20]
b. In which of the following settings were they identified?
School
Child Welfare Agency
Juvenile Justice Agency
Law Enforcement Agency
Substance Abuse Agency
Physical Health Agency (e.g., primary care, pediatrician’s office, etc.)
Emergency Room
Mental Health Agency
Other (please describe: __________________________________)
c. What was the setting where most of these identifications were made?
School
Child Welfare Agency
Juvenile Justice Agency
Law Enforcement Agency
Substance Abuse Agency
Physical Health Agency (e.g., primary care, pediatrician’s office, etc.)
Emergency Room
Physical Health Agency
Mental Health Agency
Other (please describe: __________________________________)
7. Okay, to what services, resources, or individuals did you refer the youth you identified?
Mental Health Agency
Psychiatric Hospital/Unit
Emergency Room
Substance Abuse Treatment Center
School Counselor
Training Exit Survey
03.02.2010
Page 4
TRAINING ID: PARTICIPANT ID:
Private Mental Health Practice
Mobile Crisis Unit
Other (please describe: ______________________________________)
8. Do you know whether the youth received the services to which they were referred?
[Interviewer Instructions: If No-skip to item #13]
a. [If Yes] Think about the youth referred. About how many of the youth you referred to
services actually received those services?
[All (100%) Almost all (75-99%) Most (50-75%) Some (25-50%) A few (1-25%) None (0)]
9. Now, think back to the most recent youth you identified and who actually received services-how satisfied are you that your training and the actions you took based on your training were
appropriate and effective?
10. Thinking about this same youth, about how many days did it take from the time you made the
referral to when they received their first service [Interviewer Instructions: If asked services
could include— Mental health assessment / treatment; Substance use assessment / treatment;
Psychiatric hospitalization; Emergency room or mobile crisis; other (please
describe:_____________________________)]?
[Less than 1 day; Less than a week; between 1 and 2 weeks; between 3 and 4 weeks; more than a month]
11. Again, thinking about this same youth, what was the first service he or she received?
[Insert list from EIRF]
Mental Health assessment
Substance use assessment
Mental Health Counseling
Substance abuse counseling
Inpatient services
Other service (please describe: _______________________________)
Don’t know
12. Did he or she receive any additional mental health services since that first appointment?
[If yes] What were they?
Mental Health assessment
Substance use assessment
Mental Health Counseling
Substance abuse counseling
Inpatient services
Family therapy
Group therapy
Medication
Other service (please describe: _______________________________)
Don’t know
Training Exit Survey
03.02.2010
Page 5
TRAINING ID: PARTICIPANT ID:
13. Okay, now that I have as much information as I need regarding youth, have you used
[training name] to identify adults (over 24 years-old) you thought might be at risk for
suicide?
[Interviewer Instructions: if asked, this should be based on what they learned during their
training]
[If No skip to #15]
a. [If Yes] About how many adults? [1-5; 6-10; 11-20; >20]
14. To what services, resources, or individuals did you refer the adults you identified?
Mental Health Agency
Psychiatric Hospital/Unit
Emergency Room
Substance Abuse Treatment Center
Private Mental Health Practice
Mobile Crisis Unit
Other (please describe: ______________________________________)
Part IV. Great, thanks, the last few questions are just about how easy or difficult you found it to
implement your training in your community, home, or workplace
15. How supportive has your community or workplace been of implementing what you learned
through the [insert name of training]
1-Not supportive at all
2-Somewhat supportive
3-Very supportive
4-No opinion
16. Of the following issues, what is the greatest facilitator of implementing youth suicide
prevention in your community or workplace?
Training/professional development opportunities
Increased community awareness
Community resources
Community collaboration
State, Tribe or agency prioritization of suicide prevention
17. Of the following issues, what is the greatest barrier to implementing youth suicide prevention
in your community or workplace?
Access to appropriate services
Lack of awareness about the problem of suicide
Time constraints
Workplace characteristics
Lack of funding
Thank you very much for your time today. Your information will be very valuable to SAMHSA
in its efforts to reduce suicide among youth. If you have any questions or concerns about this
survey, please contact [Insert contact information]
Training Exit Survey
03.02.2010
Page 6
TRAINING ID: PARTICIPANT ID:
*Participants will be asked to complete knowledge and post training behavior questions from
one of three training modules based on the type of training they participated in (QPR/other brief
gatekeeper training, AMSR/RRSR or Campus Connect).
1. QPR AND OTHER BRIEF GATEKEEPER TRAININGS MODULE (also default module
for locally developed gatekeeper training if no local exit survey)
Now that you have received the QPR Gatekeeper training, please indicate how you would rate your
knowledge of suicide in the following areas?
16. Facts concerning Suicide Prevention:
Very Low
Low
Medium
High
Very High
17. Warning signs of suicide:
Very Low
Low
Medium
High
Very High
18. How to ask someone about suicide:
Very Low
Low
Medium
High
Very High
19. Persuading someone to get help:
Very Low
Low
Medium
High
Very High
20. How to get help for someone:
Very Low
Low
Medium
High
Very High
21. Information about resources for help with suicide:
Very Low
Training Exit Survey
03.02.2010
Page 7
TRAINING ID: PARTICIPANT ID:
Low
Medium
High
Very High
22. Please rate what you feel is the appropriateness of asking someone who may be at risk about suicide.
Very Low
Low
Medium
High
Very High
23. What is the likelihood you will ask someone who appears to be at risk if they are
thinking of suicide?
Very Low
Low
Medium
High
Very High
24. Please rate your level of understanding about suicide and suicide prevention.
Very Low
Low
Medium
High
Very High
This section contains a list of statements of what you may think or believe about suicide
prevention. Please read each statement and use the rating scale to indicate the degree to which you agree
or disagree with it. There are no right or wrong answers. It is important that you answer all statements
according to your beliefs and not what you think others may want you to believe.
25. If someone I knew was showing signs of suicide, I would directly raise the question of
suicide with them.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
26. If a person's words and/or behavior suggest the possibility of suicide, I would ask the
person directly if he/she is thinking about suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
27. If someone told me they were thinking of suicide, I would intervene
Training Exit Survey
03.02.2010
Page 8
TRAINING ID: PARTICIPANT ID:
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
28. I feel confident in my ability to help a suicidal person
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
29. I don't think I can prevent someone from suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
30. I don’t feel competent to help a person at risk of suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Training Exit Survey
03.02.2010
Page 9
TRAINING ID: PARTICIPANT ID:
2. AMSR AND RRSR MODULE (also default module for other clinical training if no locallydeveloped exit survey)
Please rate the extent to which the workshop increased your knowledge in the following areas:
1. Managing one’s own reactions to suicide.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
2. Reconciling the difference (and potential conflict) between the clinician’s goal to prevent suicide
and the client’s goal to eliminate psychological pain via suicidal behavior.
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
e.
3. Eliciting suicide ideation, behavior, plans and intent.
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
4. Collaboratively developing a crisis response plan.
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
5. Developing a written treatment and services plan that addresses the client’s immediate, acute, and
continuing suicide ideation and risk for suicide behaviors
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
6. Developing policies and procedures for following clients closely, including taking reasonable
steps to be proactive.
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
Section II: Suicide Prevention Self-Efficacy
Training Exit Survey
03.02.2010
Page 10
TRAINING ID: PARTICIPANT ID:
1) I am able to maintain a collaborative, non-adversarial stance by creating an atmosphere in
which the client feels safe in sharing information about suicidal thoughts, behaviors and
plans
Expert 10
9
8
7
6
5
4
3
2
1 Novice
2) I am able to demonstrate an understanding of suicide-related risk and protective factors by
asking questions about suicide-related risk and protective factors during assessment.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
3) I am able to collect accurate assessment information about suicide-related risk by eliciting
risk and protective factors during the clinical interview and obtaining records and
information from collateral sources as appropriate.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
3
2
1 Novice
4) I am able to identify warning signs of acute risk of suicide.
Expert 10
9
8
7
6
5
4
5) I am able to integrate a risk assessment for suicidality into a clinical interview
Expert 10
9
8
7
6
5
4
3
2
1 Novice
6) I am able to document assessment information from a bio-psycho-social and cultural
perspective
Expert 10
9
8
7
6
5
4
3
2
1 Novice
7) I am able to demonstrate an understanding of suicide-related risk and protective factors by
considering all relevant factors when formulating risk
Expert 10
9
8
7
6
5
4
3
2
1 Novice
8) I am able to collect accurate assessment information about suicide-related risk by eliciting
suicide ideation, behavior and plans and warning signs of acute risk
Expert 10
Training Exit Survey
03.02.2010
9
8
7
6
5
4
3
2
1 Novice
Page 11
TRAINING ID: PARTICIPANT ID:
9) I am able to make a clinical judgment of risk that a client will attempt or complete suicide in
the short and long term by working collaboratively with other professionals in an interdisciplinary team approach to integrate and prioritize all the information that has been
collected, including a consideration of developmental, cultural and gender-related issues
related to suicidality.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
10) I am able to document formulation of risk, including interaction with professional colleagues,
and write a sound rationale for clinical judgment.
Expert 10
Training Exit Survey
03.02.2010
9
8
7
6
5
4
3
2
1 Novice
Page 12
TRAINING ID: PARTICIPANT ID:
3. Campus Connect Module
Section I: Suicide Prevention Knowledge and Self-Efficacy
Not at all
True
1.
I understand the meaning of
various suicide terms
(i.e., threat, attempt, survivor of
suicide).
Very
True
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
3. I am aware of the various
factors related to suicide.
1
2
3
4
5
6
7
8
9
10 risk
4. I know how to ask someone
if they are thinking about suicide.
1
2
3
4
5
6
7
8
9
10
5. I understand the potential
impact of paraphrasing emotions.
1
2
3
4
5
6
7
8
9
10
4
5
6
7
8
2
3
4
5
6
9
10
2. I am familiar with the
prevalence rates of suicidal ideation
and suicide attempts among college
students.
6. I am familiar with the available
referral resources for emotionally
distressed students.
1
7.
I feel comfortable asking
someone if they are thinking about suicide.
8.
I feel comfortable paraphrasing
emotions..
2
3
1
9
7
10
8
1
2
3
4
5
6
7
8
9
10
9. I believe I am able to emotionally
connect with students in crisis.
1
2
3
4
5
6
7
8
9
10
10. I feel comfortable attempting to
emotionally connect with students
in crisis.
1
2
3
4
5
6
7
8
9
10
11. I feel capable of helping students in
crisis feel understood.
1
2
3
4
5
6
7
8
9
10
12. I feel able to assist emotionally
1
2
3
4
5
6
7
8
9
10
Training Exit Survey
03.02.2010
Somewhat
True
Page 13
TRAINING ID: PARTICIPANT ID:
distressed students in accessing available
referral resources.
13. I believe that distressed students
will follow through with referrals I
provide to them.
Training Exit Survey
03.02.2010
1
2
3
4
5
6
7
8
9
10
Page 14
Document D.1
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 .67 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
Training Utilization and Preservation Key Informant
INTERVIEW GUIDE
Date: (Today’s Date) //
Site: (Name of Grantee) ____________________ [Select from Pull-down menu]
Participant ID:
Interviewer:
__________________________[Select from Pull-down menu]
Verbal consent provided:
1=yes
2= no
Instructions to Interviewer: When to use: Approximately two months following the
administration of the Training Exit Survey following each grant-sponsored training event. The
local site evaluator will assist the cross-site evaluation team to select trainees to participate in
this interview. The questions on this survey are designed to obtain trainee feedback on: (1) the
content, topics and/or concepts of the training, (2) utilization of the training, and (3) penetration
of the skills and/or knowledge learned through the training. Administered by: Staff from the ICF
Macro International cross-site evaluation team. Completed by: A sample of trainees who are part
of a referral network and who have attended suicide prevention awareness, early identification,
or assessment trainings (e.g., awareness, QPR, LivingWorks-ASIST).
Verbal consent:
Hello, my name is [INSERT INTERVIEWER NAME, and I'm calling to talk to you about the
training that you attended on [INSERT TRAINING DATE]. Is now a good time for me to give
you more information?
IF NO: Is there a better time to call back?
IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for
Macro International, a company that has been contracted to conduct a cross-site evaluation of
suicide prevention programs funded by SAMHSA (which stands for the Substance Abuse and
Mental Health Services Administration). As part of this evaluation, we are interviewing a
sample of people who have attended a suicide prevention training. We hope to learn more about
the trainings, how you used what you learned, and the impact of the training on the communities
you serve. I'm contacting you because you were selected to participate in these interviews. If
you decide to participate, the interviews will take no more than 20 or 30 minutes, and you will
receive $20 for your time. If you are interested I will give you some more information and get
your verbal consent. Can I continue?
We are conducting up to 10 interviews with a small sample of trainees from the training you
participated in, as well as with people who have participated in other suicide prevention trainings
as part of these SAMHSA-funded programs across the nation. This is why your input is so
important.
Before I ask you whether you agree to be interviewed, there are a few more things that you
should know:
- Your answers will in no way be linked to your name and your name will never
appear in any report that summarizes the findings of the cross-site evaluation.
- You can choose to stop the interview at any time or not answer a question for
whatever reason. If you stop the interview, at your request, we will destroy the survey.
- In addition, to protect the information that you give us, we have obtained a
Certificate of Confidentiality from the United States Department of Health and Human Services.
The Certificate of Confidentiality will protect the members of the research staff from being
forced, even under a subpoena, to release any information in which you are identified.
Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or
information regarding imminent danger to yourself or others, which we will report to the
appropriate local and state agency. Additionally, DHHS may see your information if we are
audited. Finally, the certificate of confidentiality does not imply the endorsement or the
disapproval of the Department of Health and Human Services.
You will receive $20 to compensate you for your time, and we will give you the $20 whether
you finish the interview or decide to withdraw before it ends.
Training Utilization and Preservation (TUP) Key Informant Interview
03.03.2010
Page 2
- I am not an expert in the subject matter, and I do not work for the people who
provided the training, so you can't hurt my feelings and there aren't any wrong answers. We're
just interested in your thoughts and opinions.
- I will be taking notes during the interview, but I would like to get your permission
to record this interview in order to make sure we have an accurate transcript of the information
you give us. If you agree to be recorded, your recording will be kept in a private file that only
Macro staff has access to and will be destroyed upon the completion of the evaluation. If you do
not wish to be recorded I will refrain from recording the interview.
- If you have any concerns about your participation in this study or have any
questions about the research, please contact Gingi Pica. Do you have a pen to take down her
contact information? It is: adrienne.g.pica@macrointernational.com, and her phone number is,
toll free: 1-866-762-1988
Do you have any questions?
Do you agree to participate in this interview?
IF YES, continue
Do I have your permission to record this interview?
IF YES, continue to Part I – Background Information
PART I: BACKGROUND INFORMATION
INTERVIEWER: During this interview, I want to discuss your participation in the [NAME
OF TRAINING] conducted by [NAME OF FACILITATOR or ORGANIZATION THAT
HOSTED THE TRAINING], on [DATE OF TRAINING]. However, before we get started I
want to hear a little bit about you, what brought you to the training, and about any other
training related to suicide prevention that you might have had in the past.
1. So, in your job or in the community, what are the main ways in which you come into
contact with youths?
PROBE: Do you regularly talk with them about matters personal to them such as
their health, family, and feelings?
2. Okay, thanks. Can you tell me what brought you to [NAME OF TRAINING]?
3. Have you attended trainings on suicide prevention other than [NAME OF
TRAINING]?
IF NO, GO TO QUESTION 6.
Training Utilization and Preservation (TUP) Key Informant Interview
03.03.2010
Page 3
IF YES,
4. What are the names of those trainings?
PROBE: Did you attend those trainings before or after the [NAME OF
TRAINING]?
INTERVIEWER INSTRUCTIONS: For each training named in
Q2 ask whether it was received before (B) or after (A) the [NAME
THE TRAINING].
INTERVIEWER INSTRUCTIONS: If the respondent participated
in trainings on suicide prevention after the [NAME OF
TRAINING], as you conduct the interview, please ensure the
respondent is talking about [NAME OF TRAINING].
PART II: TRAINING CONTENT
INTERVIEWER: Ok, thanks. Now, I am going to ask you a few questions about what you
learned in the training.
5. First, thinking back to the [NAME OF TRAINING] training you attended, what would
you say was the main purpose of the training?
PROBE:
Can you describe what happened at the training?
PROBE:
for specifics. Example: what were some of the warning signs you
learned? How were you taught to intervene? What were some of the communication
techniques they presented?
PROBE:
What skills did you learn? What other concepts did you learn?
PROBE:
Can you remember anything else?
6. What information was new to you?
PROBE:
What?
Did anything make you see things differently than you had before?
7. Did the trainer use any techniques or activities that helped you learn the material?
What were they?
PROBE:
Anything else?
Training Utilization and Preservation (TUP) Key Informant Interview
03.03.2010
Page 4
8. Did you receive any materials that you found useful?
PROBE:
9.
Have you used any of these materials since the training?
So, thinking of the information and skills that you just described, what has been the
most useful to you?
PROBE:
How has that been useful?
10. On the opposite side, was there anything about the training that you didn’t like or did
not find useful?
11. Would you recommend changing or adapting the training in any way?
PART III: TRAINING UTILIZATION AND IMPACT
INTERVIEWER: Great, thanks. We also want to hear about how you may have used what
you learned in the [NAME OF TRAINING].
12. First, try to think back to an instance before participating in [NAME OF TRAINING]
when you interacted with a youth whom you thought might be at risk for suicide—and
tell me about that situation?
Probe:
How did you know he or she was at risk?
Probe:
What actions did you take to connect he or she with appropriate
services?
Probe:
Did you feel confident in your ability to meet the needs of him or her?
[Insert scale—very confident to very unsure]
13. Now, since your [NAME OF TRAINING] training, how have you used what you
learned in your interactions with youth?
PROBE:
Specifically, how have you used what you learned in the [NAME OF
TRAINING]?
PROBE:
How often have you used what you learned in [NAME OF
TRAINING]?
[Insert scale: daily, weekly, monthly]
PROBE:
With how many youth have you been able to use what you learned
[NAME OF TRAINING]? {add instructions?}
[Insert scale: (<10; 10-20; 20-50; >50)]
PROBE:
Have you had the opportunity to and used the training to intervene
with a youth you felt was at risk for suicide? [IF YES] how many?
Training Utilization and Preservation (TUP) Key Informant Interview
03.03.2010
Page 5
PROBE:
Has your communication with youth about their suicide or mental
health-related issues changed since your training? If so, how?
14. Okay, now thinking about a specific instance since you were trained, when you
interacted with a youth you thought might be at risk for suicide, how did you use
[NAME OF TRAINING]?
PROBE:
Where did you refer the youth for additional help?
PROBE:
How well do you think your training prepared you for that situation?
[Insert scale—very well to very poorly]
15. How does the [NAME OF TRAINING] effect your comfort sharing suicide prevention
information with others (e.g., parents, family members, co-workers, etc.)?
PART IV: CONCLUSION
I have a few final questions for you about things that help or that may get in the way of
your own suicide prevention efforts and the efforts of your community.
17. In your day-to-day contact with youth or other individuals who might be at risk for
suicide, what are the barriers to using what you learned in the [NAME OF
TRAINING]?
PROBE:
How?
18. Thinking about the bigger picture, what are the aspects of your community or
workplace that make it difficult to implement the suicide prevention skills you learned?
19. And now on the opposite side, what are some of the aspects of your community or
workplace that have helped you use what you learned in the training?
PROBE:
For example, supportive co-workers, funding for materials
and/or training, access to resources and services, etc.?
PROBE:
How have these factors aided your ability to use what you
learned in the [NAME OF TRAINING]?
20. One last question for you: Would you like to receive any additional training in suicide
prevention?
PROBE:
What skills would you be interested in learning or practicing?
INTERVIEWER: That is the last of my questions, is there anything else that you would like
to share about the [NAME OF TRAINING] and/or how it meet (or not) your expectations
for development of suicide prevention knowledge and skills?
Training Utilization and Preservation (TUP) Key Informant Interview
03.03.2010
Page 6
What questions or clarifications do you have about any of the issues that we have
discussed?
INTERVIEWER: Thank you for your time and willingness to participate in this interview,
your information will be combined with others who participated in the [NAME OF
TRAINING] to get a better understanding of how attendees have been able to use the
information they were presented and impact the youth and communities in which they
work.
______________________________________________________________________________
Training Utilization and Preservation (TUP) Key Informant Interview
03.03.2010
Page 7
Document E
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 .67 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 Youth Suicide Prevention and
Early Intervention Program—State/Tribal Component
Referral Network Survey
/ASK ALL/
INTRO1. Hello, my name is [INSERT NAME] and I work for ICF Macro International Inc. ICF
Macro is conducting the cross-site evaluation of the Garrett Lee Smith Memorial (GLS)
State/Tribal Youth Suicide Prevention and Early Intervention Program on behalf of the
Substance Abuse and Mental Health Services Administration (SAMHSA). Because your
organization is involved in coordinating community suicide prevention efforts, or is responsible
for identifying and/or serving youth at risk for suicide your organization has been selected for
this survey.
01 CONTINUE
/if INTRO1=01/
CONFIDENTIALITY STATEMENT: The survey asks about your organization’s involvement
in your local suicide prevention network. This survey is being conducted to better understand the
early identification and referrals of youth at risk for suicide in your community. Participation is
completely voluntary and you can end the interview at any time or refuse to answer any question.
All responses will be kept completely confidential. Contact information will be entered into a
password-protected database which can only be accessed by a limited number of individuals
(selected ICF Macro staff - telephone interviewers and cross-site team members) who require
access. These individuals have signed confidentiality, data access and use agreements. Your
name will not be used in any reports, but your agency and/or organization and the information
you provide about your agency or organization may be identifiable when reporting results.
However, your input will help gain a better understanding of the systems and networks in place
to help youth identified at risk for suicide in your community. The survey will take
approximately 40 minutes and the findings will assist in informing the Substance Abuse and
Mental Health Services Administration (SAMHSA) about suicide prevention activities and
network processes. This call may be monitored for quality assurance purposes.
You may contact the cross-site evaluation project director with any questions that you have about
the evaluation and/or Referral Network Survey before, during, or after you have completed the
survey.
We will provide you contact information for the project director who you may contact with any
questions that arise after your participation in this interview. If you have any concerns about your
participation in this survey or have any questions about the evaluation, please contact Chad Rodi,
Project Director, 917.407.9894.
You will receive a copy of this consent form via email or regular mail.
/ASK ALL/
CONSENT. Do you agree to participate in this interview?
01
YES (Verbal Consent Provided)
02
NO
/IF CONSENT=02/
TERM1. Thank you for your time and consideration of participation in the Referral Network
Survey. /TERMINATE/
/IF CONSENT=01/
RECORD. Thank you! We would also like to get you permission to record this interview to
ensure that we accurately capture details that you provide. However, if you do not agree to
be recorded, we will not record the interview. If you agree to be recorded, only cross-site
evaluation staff will be able to access the recording. To protect your privacy, we will keep
the notes and recordings in private files and only study staff will be allowed to use them.
All tapes will be destroyed at the end of the evaluation, approximately 3 years from now.
Your name and other information linking your name to what is said during the groups will
not be reported when we present this study or publish its results. Do I have your
permission to record the interview?
01
02
YES
NO
/IF CONSENT=01/
SCHEDULE. I’m glad that you consent to be interviewed. Let’s set up a date and time most
convenient for you to conduct the 40-minute interview.
01 ENTER CALLBACK DATE/TIME
02 START INTERVIEW
/IF SCHEDULE=01/
REMINDER. Also, I would like to send you an electronic reminder before our interview. Can
you please confirm your name, address, phone number, and e-mail address?
/PROGRAMMER, INSERT NAME, ADDRESS, WORK PHONE, CELL PHONE,
AND EMAIL ADDRESS FROM SAMPLE, ALLOW INTERVIEWER TO MODIFY/
/IF SCHEDULE=01/
TERM2. Please contact me at [PHONE NUMBER] if your schedule changes so that we can
reschedule a time to talk. Otherwise, I look forward to talking with you on
[Month/Day/Year] at [Time].
/ASK ALL/
INTRO2. The survey asks questions about the connections between your organization and the
other organizations in your local suicide prevention network.
/ASK ALL/
1.
First, can you please tell me a little about the type of organization you work for? Is it
primarily a…
[read all code only one]
01
Mental health/behavioral health agency
02
Child welfare services (i.e. social services) agency
03
K-12 School
04
Juvenile justice agency
05
Police/Law enforcement agency
06
State health department agency
07
Primary care provider
08
Local health department
09
Crisis center
10
Tribal health agency
11
Tribal social service agency
12
Tribal government
13
College or university
14
Private, non-profit community service organization
95
Other
97
99
DON’T KNOW
REFUSED
/IF Q1=14/
1OTH_1. Please describe
/IF Q1=95/
1OTH_2. Please describe
/ASK ALL/
2.
About how many staff members are employed by your organization?
__ __ NUMBER OF STAFF MEMBERS
97
DON’T KNOW
99
REFUSED
/ASK ALL/
3.
Are you the only individual in your organization responsible for directly addressing the
needs of youths identified at risk for suicide?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/IF Q3=01, INSERT “YOU” IN SUBSEQUENT QUESTIONS, IF Q3=02, INSERT “YOUR
ORGANIZATION” IN SUBSEQUENT QUESTIONS/
/ASK ALL/
For the next few questions, I am interested in how [you/your organization] work with youth atrisk for suicide around referrals for mental health services:
/ASK ALL/
4a.
[Do you/Does your organization] refer youth at-risk for suicide for mental health
services?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
4b.
[Do you/Does your organization] receive youth at-risk for suicide who have been referred
by others for mental health services?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
4c.
Neither you or your organization receives or make referrals (provide direct services) but
facilitates suicide prevention efforts through administrative assistance (i.e. providing
trainings, consulting with communities, etc.).
01
YES
02
97
99
NO
DON’T KNOW
REFUSED
/ASK ALL/
Q5INTRO. During this section of the interview, I am going to ask you about the types of
linkages, partnerships, and collaborations your agency/organization has had with other
organizations as it relates to youth referrals for suicide ideation during the last 12 months.
The following organizations were previously identified as part of your community’s
suicide prevention referral network by the Garrett Lee Smith grant-funded suicide
prevention program staff. As I read the list of the organizations, please keep in mind your
interactions with each agency as it relates to suicide prevention and related activities. I
will ask you to rate the quality of those relationships.
/ASK ALL/
5.
Have you worked with [insert agency/organization name here] around suicide
prevention? (NOTE TO INTERVIEWER: each question A through G will need to be
asked for each agency/organization listed which may total 5 times).
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
a. Thinking back to the last 12 months, how would you rate the quality of the relationship
between [insert organization or individual name here] and your organization around
administration of suicide prevention efforts and decision-making?
INTERVIEWER, IF NECESSARY: For example, relationships around making policies,
program decisions, budgeting decisions, and staff decisions.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
b.
Again thinking back to the last 12 months. How would you rate the quality of the
relationship between [insert organization or individual name here] and your organization
around sharing information related to suicide prevention efforts such as
communicating training opportunities, communicating referral and crisis protocols?
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
c.
How would you rate the quality of the relationship between [insert organization or
individual name here] and your organization in sharing resources to support the
suicide prevention program? I’m only interested in the actual use of resources in this
question. Examples of the resources I am referring to are the sharing of staff, providing
funding, etc.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
d.
How would you rate the quality of the relationship between [insert organization or
individual name here] and your organization in providing referrals for youth in need of
service as part of a suicide prevention effort with other agencies or organizations?
INTERVIEWER, IF NECESSARY: This question refers to where your agency or
organization provides referrals of at risk youth to other agencies or organizations.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
e.
How would you rate the quality of the relationship between [insert organization or
individual name here] and your organization around receiving referrals for youth in
need of service as part of suicide prevention efforts. For example, relationships with
other agencies/organizations where YOUR agency/organization receives referrals from
other agencies/organizations?
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
f.
How would you rate the quality of the relationship between [[insert organization or
individual name here] and your organization around the coordination of early
identification or gatekeeper training activities? For example, relationships around
providing or receiving gatekeeper training related to suicide prevention, etc.
INTERVIEWER, IF NECESSARY: This question refers to coordinating suicide
prevention gatekeeper training activities.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
g.
How would you rate the overall quality of the relationship between [insert organization or
individual name here] and your organization around following-up with youth who have
attempted suicide?
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
6.
What recommendations would you have to improve/enhance collaboration among
individuals and organizations around referral and follow-up of youths at-risk for suicide?
01
97
99
GAVE RESPONSE
DON’T KNOW
REFUSED
/ASK IF Q6=01/
Q6TEXT.
/ASK ALL/
Q7INTRO. Thank you. That was the last question in that section. The next section asks about
your organization’s policies and protocols regarding follow-up for youths who have
attempted suicide and who are at risk for suicide.
/ASK ALL/
7.
Do you or your organization have a process for addressing the needs of youths who
attempt suicide and their families?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
8.
Thinking back to the “process” that you referred to in the previous question, is this
process (e.g. policy/protocol) formal in that it is a written policy or an informal
procedure?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
9.
In reference to your own organization, is there a designated individual who is responsible
for training and supervising crisis service management for youth and their families?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
10.
Does your organization provide regular crisis education or training for personnel?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
/MUL=8/
11.
Which of the following are mandated under your policy or protocol?
INTERVIEWER: SELECT ALL THAT APPLY
01
02
07
95
Mental health assessment
Safety planning [IF SO]
03
Instruction to families for after hours help
04
Safety in the home [IF SO]
05
Removal of firearms
06
Limiting access to medications
Immediate referrals to emergency or crisis services
Other service
97
99
DON’T KNOW
REFUSED
/ASK IF Q11=95/
11OTH.
ENTER OTHER SERVICE
/ASK IF Q7=01/
12.
Does your organization have a system in place that allows you to know if a client or their
family followed through with safety recommendations, treatment referrals, etc.?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
13.
Do you or your organization have a policy or protocol for making referrals?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q13=01/
/MUL=7/
14.
Which of the following agency(s) does your organization refer suicidal clients:
INTERVIEWER: SELECT ALL THAT APPLY
01
02
03
04
05
06
95
Emergency services
Mental health counseling
Substance abuse counseling
Inpatient or residential services
Support groups (e.g. bereavement or survivors’ organizations)
Provide referrals to direct service
Other service
97
99
DON’T KNOW
REFUSED
/ASK IF Q14=95/
14OTH.
ENTER OTHER SERVICE
/ASK ALL/
15.
[Do you/Does your organization] provide direct services?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q15=01/
/MUL=10/
16.
What are the services available from [you/your organization] for youth who have
attempted suicide and their families?
INTERVIEWER: SELECT ALL THAT APPLY
01
02
03
04
05
06
07
08
09
Emergency services
Safety planning
Mental health assessment
Substance use assessment
Mental health counseling
Substance abuse counseling
Inpatient or residential services
Support groups (e.g. bereavement or survivors’ organizations)
Provide referrals to direct service
95
Other service
97
DON’T KNOW
99
REFUSED
/ASK IF Q16=95/
16OTH.
ENTER OTHER SERVICE
/ASK ALL/
17.
Does your organization have a policy or protocol for tracking information about youth
who have attempted suicide? Information might include their mental health status, service
receipt, treatment participation, suicide attempt or re-attempt, etc.
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q17=01/
18INTRO. In the next set of questions I’m going to ask you about you or your organizations
access to electronic databases.
/ASK IF Q17=01/
18.
Is information about at-risk youth maintained in an electronic database?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q18=01/
19.
Is the information accessible by individuals in your own organization?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q18=01/
20.
To your knowledge, is the information in that database available and accessible to the
other individuals or agencies in the referral network and mentioned in the earlier
questions about organizational relationships.
01
02
03
Yes, one or some of those organizations
Yes, all of those organizations
No, none of those organizations
97
99
DON’T KNOW
REFUSED
/ASK ALL/
21INTRO. This last section asks additional questions about electronic databases that have
information about mental health service utilization and mental health epidemiology.
/ASK ALL/
21.
In addressing youth suicide prevention, do you or your organization access any electronic
databases?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q21=01/
/MUL=4/
22.
Which of the following [do you/does your organization] use?
INTERVIEWER: SELECT ALL THAT APPLY
01
95
Epidemiological data (i.e. prevalence and type of suicide-related risk and
protective factors, mortality, morbidity)
Mental health service utilization data (e.g., use of mental health or other relevant
support services by youth and their families)
Non-mental health service utilization data (e.g., primary health care, substance
abuse treatment, juvenile justice, education)
Other
97
99
DON’T KNOW
REFUSED
02
03
/ASK IF Q22=95/
22OTH.
ENTER OTHER
/ASK ALL/
CLOSING: Thank you for your time and willingness to participate in this interview, the
information that you have provided will be invaluable. The information collected here
today will help the evaluation team understand how agencies/organizations collaborate on
suicide prevention efforts.
Document E
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 .67 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 Youth Suicide Prevention and
Early Intervention Program—State/Tribal Component
Referral Network Survey
/ASK ALL/
INTRO1. Hello, my name is [INSERT NAME] and I work for ICF Macro International Inc. ICF
Macro is conducting the cross-site evaluation of the Garrett Lee Smith Memorial (GLS)
State/Tribal Youth Suicide Prevention and Early Intervention Program on behalf of the
Substance Abuse and Mental Health Services Administration (SAMHSA). Because your
organization is involved in coordinating community suicide prevention efforts, or is responsible
for identifying and/or serving youth at risk for suicide your organization has been selected for
this survey.
01 CONTINUE
/if INTRO1=01/
CONFIDENTIALITY STATEMENT: The survey asks about your organization’s involvement
in your local suicide prevention network. This survey is being conducted to better understand the
early identification and referrals of youth at risk for suicide in your community. Participation is
completely voluntary and you can end the interview at any time or refuse to answer any question.
All responses will be kept completely confidential. Contact information will be entered into a
password-protected database which can only be accessed by a limited number of individuals
(selected ICF Macro staff - telephone interviewers and cross-site team members) who require
access. These individuals have signed confidentiality, data access and use agreements. Your
name will not be used in any reports, but your agency and/or organization and the information
you provide about your agency or organization may be identifiable when reporting results.
However, your input will help gain a better understanding of the systems and networks in place
to help youth identified at risk for suicide in your community. The survey will take
approximately 40 minutes and the findings will assist in informing the Substance Abuse and
Mental Health Services Administration (SAMHSA) about suicide prevention activities and
network processes. This call may be monitored for quality assurance purposes.
You may contact the cross-site evaluation project director with any questions that you have about
the evaluation and/or Referral Network Survey before, during, or after you have completed the
survey.
We will provide you contact information for the project director who you may contact with any
questions that arise after your participation in this interview. If you have any concerns about your
participation in this survey or have any questions about the evaluation, please contact Chad Rodi,
Project Director, 917.407.9894.
You will receive a copy of this consent form via email or regular mail.
/ASK ALL/
CONSENT. Do you agree to participate in this interview?
01
YES (Verbal Consent Provided)
02
NO
/IF CONSENT=02/
TERM1. Thank you for your time and consideration of participation in the Referral Network
Survey. /TERMINATE/
/IF CONSENT=01/
RECORD. Thank you! We would also like to get you permission to record this interview to
ensure that we accurately capture details that you provide. However, if you do not agree to
be recorded, we will not record the interview. If you agree to be recorded, only cross-site
evaluation staff will be able to access the recording. To protect your privacy, we will keep
the notes and recordings in private files and only study staff will be allowed to use them.
All tapes will be destroyed at the end of the evaluation, approximately 3 years from now.
Your name and other information linking your name to what is said during the groups will
not be reported when we present this study or publish its results. Do I have your
permission to record the interview?
01
02
YES
NO
/IF CONSENT=01/
SCHEDULE. I’m glad that you consent to be interviewed. Let’s set up a date and time most
convenient for you to conduct the 40-minute interview.
01 ENTER CALLBACK DATE/TIME
02 START INTERVIEW
/IF SCHEDULE=01/
REMINDER. Also, I would like to send you an electronic reminder before our interview. Can
you please confirm your name, address, phone number, and e-mail address?
/PROGRAMMER, INSERT NAME, ADDRESS, WORK PHONE, CELL PHONE,
AND EMAIL ADDRESS FROM SAMPLE, ALLOW INTERVIEWER TO MODIFY/
/IF SCHEDULE=01/
TERM2. Please contact me at [PHONE NUMBER] if your schedule changes so that we can
reschedule a time to talk. Otherwise, I look forward to talking with you on
[Month/Day/Year] at [Time].
/ASK ALL/
INTRO2. The survey asks questions about the connections between your organization and the
other organizations in your local suicide prevention network.
/ASK ALL/
1.
First, can you please tell me a little about the type of organization you work for? Is it
primarily a…
[read all code only one]
01
Mental health/behavioral health agency
02
Child welfare services (i.e. social services) agency
03
K-12 School
04
Juvenile justice agency
05
Police/Law enforcement agency
06
State health department agency
07
Primary care provider
08
Local health department
09
Crisis center
10
Tribal health agency
11
Tribal social service agency
12
Tribal government
13
College or university
14
Private, non-profit community service organization
95
Other
97
99
DON’T KNOW
REFUSED
/IF Q1=14/
1OTH_1. Please describe
/IF Q1=95/
1OTH_2. Please describe
/ASK ALL/
2.
About how many staff members are employed by your organization?
__ __ NUMBER OF STAFF MEMBERS
97
DON’T KNOW
99
REFUSED
/ASK ALL/
3.
Are you the only individual in your organization responsible for directly addressing the
needs of youths identified at risk for suicide?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/IF Q3=01, INSERT “YOU” IN SUBSEQUENT QUESTIONS, IF Q3=02, INSERT “YOUR
ORGANIZATION” IN SUBSEQUENT QUESTIONS/
/ASK ALL/
For the next few questions, I am interested in how [you/your organization] work with youth atrisk for suicide around referrals for mental health services:
/ASK ALL/
4a.
[Do you/Does your organization] refer youth at-risk for suicide for mental health
services?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
4b.
[Do you/Does your organization] receive youth at-risk for suicide who have been referred
by others for mental health services?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
4c.
Neither you or your organization receives or make referrals (provide direct services) but
facilitates suicide prevention efforts through administrative assistance (i.e. providing
trainings, consulting with communities, etc.).
01
YES
02
97
99
NO
DON’T KNOW
REFUSED
/ASK ALL/
Q5INTRO. During this section of the interview, I am going to ask you about the types of
linkages, partnerships, and collaborations your agency/organization has had with other
organizations as it relates to youth referrals for suicide ideation during the last 12 months.
The following organizations were previously identified as part of your community’s
suicide prevention referral network by the Garrett Lee Smith grant-funded suicide
prevention program staff. As I read the list of the organizations, please keep in mind your
interactions with each agency as it relates to suicide prevention and related activities. I
will ask you to rate the quality of those relationships.
/ASK ALL/
5.
Have you worked with [insert agency/organization name here] around suicide
prevention? (NOTE TO INTERVIEWER: each question A through G will need to be
asked for each agency/organization listed which may total 5 times).
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
a. Thinking back to the last 12 months, how would you rate the quality of the relationship
between [insert organization or individual name here] and your organization around
administration of suicide prevention efforts and decision-making?
INTERVIEWER, IF NECESSARY: For example, relationships around making policies,
program decisions, budgeting decisions, and staff decisions.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
b.
Again thinking back to the last 12 months. How would you rate the quality of the
relationship between [insert organization or individual name here] and your organization
around sharing information related to suicide prevention efforts such as
communicating training opportunities, communicating referral and crisis protocols?
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
c.
How would you rate the quality of the relationship between [insert organization or
individual name here] and your organization in sharing resources to support the
suicide prevention program? I’m only interested in the actual use of resources in this
question. Examples of the resources I am referring to are the sharing of staff, providing
funding, etc.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
d.
How would you rate the quality of the relationship between [insert organization or
individual name here] and your organization in providing referrals for youth in need of
service as part of a suicide prevention effort with other agencies or organizations?
INTERVIEWER, IF NECESSARY: This question refers to where your agency or
organization provides referrals of at risk youth to other agencies or organizations.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
e.
How would you rate the quality of the relationship between [insert organization or
individual name here] and your organization around receiving referrals for youth in
need of service as part of suicide prevention efforts. For example, relationships with
other agencies/organizations where YOUR agency/organization receives referrals from
other agencies/organizations?
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
f.
How would you rate the quality of the relationship between [[insert organization or
individual name here] and your organization around the coordination of early
identification or gatekeeper training activities? For example, relationships around
providing or receiving gatekeeper training related to suicide prevention, etc.
INTERVIEWER, IF NECESSARY: This question refers to coordinating suicide
prevention gatekeeper training activities.
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
g.
How would you rate the overall quality of the relationship between [insert organization or
individual name here] and your organization around following-up with youth who have
attempted suicide?
01
02
03
04
05
Extremely low
Somewhat low
No opinion
Somewhat high
Extremely high
97
99
DON’T KNOW
REFUSED
/ASK ALL/
6.
What recommendations would you have to improve/enhance collaboration among
individuals and organizations around referral and follow-up of youths at-risk for suicide?
01
97
99
GAVE RESPONSE
DON’T KNOW
REFUSED
/ASK IF Q6=01/
Q6TEXT.
/ASK ALL/
Q7INTRO. Thank you. That was the last question in that section. The next section asks about
your organization’s policies and protocols regarding follow-up for youths who have
attempted suicide and who are at risk for suicide.
/ASK ALL/
7.
Do you or your organization have a process for addressing the needs of youths who
attempt suicide and their families?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
8.
Thinking back to the “process” that you referred to in the previous question, is this
process (e.g. policy/protocol) formal in that it is a written policy or an informal
procedure?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
9.
In reference to your own organization, is there a designated individual who is responsible
for training and supervising crisis service management for youth and their families?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
10.
Does your organization provide regular crisis education or training for personnel?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q7=01/
/MUL=8/
11.
Which of the following are mandated under your policy or protocol?
INTERVIEWER: SELECT ALL THAT APPLY
01
02
07
95
Mental health assessment
Safety planning [IF SO]
03
Instruction to families for after hours help
04
Safety in the home [IF SO]
05
Removal of firearms
06
Limiting access to medications
Immediate referrals to emergency or crisis services
Other service
97
99
DON’T KNOW
REFUSED
/ASK IF Q11=95/
11OTH.
ENTER OTHER SERVICE
/ASK IF Q7=01/
12.
Does your organization have a system in place that allows you to know if a client or their
family followed through with safety recommendations, treatment referrals, etc.?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK ALL/
13.
Do you or your organization have a policy or protocol for making referrals?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q13=01/
/MUL=7/
14.
Which of the following agency(s) does your organization refer suicidal clients:
INTERVIEWER: SELECT ALL THAT APPLY
01
02
03
04
05
06
95
Emergency services
Mental health counseling
Substance abuse counseling
Inpatient or residential services
Support groups (e.g. bereavement or survivors’ organizations)
Provide referrals to direct service
Other service
97
99
DON’T KNOW
REFUSED
/ASK IF Q14=95/
14OTH.
ENTER OTHER SERVICE
/ASK ALL/
15.
[Do you/Does your organization] provide direct services?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q15=01/
/MUL=10/
16.
What are the services available from [you/your organization] for youth who have
attempted suicide and their families?
INTERVIEWER: SELECT ALL THAT APPLY
01
02
03
04
05
06
07
08
09
Emergency services
Safety planning
Mental health assessment
Substance use assessment
Mental health counseling
Substance abuse counseling
Inpatient or residential services
Support groups (e.g. bereavement or survivors’ organizations)
Provide referrals to direct service
95
Other service
97
DON’T KNOW
99
REFUSED
/ASK IF Q16=95/
16OTH.
ENTER OTHER SERVICE
/ASK ALL/
17.
Does your organization have a policy or protocol for tracking information about youth
who have attempted suicide? Information might include their mental health status, service
receipt, treatment participation, suicide attempt or re-attempt, etc.
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q17=01/
18INTRO. In the next set of questions I’m going to ask you about you or your organizations
access to electronic databases.
/ASK IF Q17=01/
18.
Is information about at-risk youth maintained in an electronic database?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q18=01/
19.
Is the information accessible by individuals in your own organization?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q18=01/
20.
To your knowledge, is the information in that database available and accessible to the
other individuals or agencies in the referral network and mentioned in the earlier
questions about organizational relationships.
01
02
03
Yes, one or some of those organizations
Yes, all of those organizations
No, none of those organizations
97
99
DON’T KNOW
REFUSED
/ASK ALL/
21INTRO. This last section asks additional questions about electronic databases that have
information about mental health service utilization and mental health epidemiology.
/ASK ALL/
21.
In addressing youth suicide prevention, do you or your organization access any electronic
databases?
01
02
97
99
YES
NO
DON’T KNOW
REFUSED
/ASK IF Q21=01/
/MUL=4/
22.
Which of the following [do you/does your organization] use?
INTERVIEWER: SELECT ALL THAT APPLY
01
95
Epidemiological data (i.e. prevalence and type of suicide-related risk and
protective factors, mortality, morbidity)
Mental health service utilization data (e.g., use of mental health or other relevant
support services by youth and their families)
Non-mental health service utilization data (e.g., primary health care, substance
abuse treatment, juvenile justice, education)
Other
97
99
DON’T KNOW
REFUSED
02
03
/ASK IF Q22=95/
22OTH.
ENTER OTHER
/ASK ALL/
CLOSING: Thank you for your time and willingness to participate in this interview, the
information that you have provided will be invaluable. The information collected here
today will help the evaluation team understand how agencies/organizations collaborate on
suicide prevention efforts.
| File Type | application/pdf |
| File Title | Trainers |
| Author | Angela.K.Sheehan |
| File Modified | 2010-05-24 |
| File Created | 2010-05-24 |