Form Campus - Student I Campus - Student I Campus - Student Instruments

Document G.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 .42 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) Campus Suicide Prevention Program

Suicide Prevention Exposure, Awareness and Knowledge
Survey (SPEAKS) - S
(Student Version)
Date: (Today’s Date) //

Site: (Name of Campus) ____________________ [Select from Pull-down menu]

Administration Wave:

1 = First wave of administration
2 = Second wave of administration

SPEAKS-S

Before you continue with this short online survey, 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
survey is voluntary and that the information you share is private.
You were selected to participate in this survey because your school, along with other
schools across the country, received federal funding to support implementation of Campus
Suicide Prevention programs. As part of the cross-site evaluation of the Campus Suicide
Prevention, we are asking that you complete this Suicide Prevention, Exposure, Awareness and
Knowledge Survey (SPEAKS). The survey includes a series of open and closed ended questions
asking you about your exposure to suicide prevention activities, and your awareness and
knowledge of suicide prevention. The findings from this survey will be used to inform the
federal agency responsible for providing funding, the Substance Abuse and Mental Health
Services Administration (SAMHSA), about suicide prevention activities on campuses.
There are not right or wrong responses to this survey and the survey will take approximately 15
minutes for you to complete. Your consent to participate in this survey requires that you
carefully read and agree to the following:
Privacy: The information that you provide via this survey will be kept private except as
otherwise required by law. Any identifying information will not be disclosed to anyone but the
researchers conducting this evaluation and will be kept in locked files separate from the data
collected. The information that we report to SAMSHA will be reported in aggregate, will not
contain any identifying information and your name will not be used in any reports about this
evaluation.
Risks: Completing this survey 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.
Benefits: Prior to completing the survey, you received a $1 incentive via standard mail with
a letter describing the survey and providing the link and password. Your participation will
not directly benefit you other than the incentive. However, the benefit of your completing this
survey is that your input will help facilitate the development of Campus suicide prevention
programs.
Your participation is voluntary. Refusal to participate involves no penalty or adverse
consequences. If you consent to participate in this survey 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 SPEAKS before, during or
after you have completed the survey.
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 survey.

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SPEAKS-S

Contact information: If you have any concerns about your participation in this survey or have
any questions about the evaluation, please contact [INSERT CONTACT NAME, TITLE AND
PHONE NUMBER]. Please click the “I CONSENT” box below to proceed to SPEAKS.
“I CONSENT” (Move to next web page to start SPEAKS)
“I DO NOT CONSENT” (Move to the web page which should say “Thank you for
your time in consideration to participate in SPEAKS. Please contact the Project Director,
Christine Walrath-Greene at 212-941-5555 with any questions,” and offer respondents an
opportunity to go to the survey Homepage.)
Thank you!

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SPEAKS-S

Thank you for agreeing to participate in this survey about suicide prevention. You were
selected to participate in this survey because your school, along with other schools across
the country, received federal funding to support implementation of Campus Suicide
Prevention Programs. Your responses to these questions are extremely important in
enhancing programs to prevent suicide on campuses.
1. Have you been exposed to any materials on your campus related to suicide prevention
(e.g., brochures, posters, videos, radio messages, orientation materials, etc.)?
 Yes
 No
 Don’t know
If Yes, what materials have you been exposed to? _______________________________
2. Have you directly participated in any suicide prevention activities sponsored by your
campus (e.g., gatekeeper training, seminar, workshop, orientation program, etc.)?
 Yes
 No
 Don’t know
If Yes, what activities have you participated in? _______________________________

Please rate your level of confidence in your ability to interact with others about the suicide
prevention behaviors described below from not confident to very confident (check one).

I feel confident that:
3. I can recognize the
warning signs of suicide
in another student.
4. I would ask someone
who was exhibiting the
warning signs of suicide
if they are thinking
about suicide.
5. I would connect or
refer a student at risk for
suicide to resources for
help (e.g., hotline,
counseling, ER, etc.).

Not
Confident

Level of Confidence
Somewhat Confident
Very
Confident
Confident

Suicide Prevention Exposure, Awareness and Knowledge Survey (SPEAKS-S)
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Don’t
know

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Next, we would like to know a little bit about your campus and resources available for
students at risk for suicide. Please respond to each of the items using the response options
provided that best represents your answer.
6. I am aware of at least one local resource to which I could refer someone who seemed at risk
for suicide.
 Yes (continue to question 7)
 No (skip to question 8)
7. If you knew a friend or fellow student that was thinking about suicide, where would you refer
him/her? (List up to 4 local resources)

8. My campus values the mental health and wellbeing of its students.
Strongly Disagree

Disagree

0

1

No Opinion

Agree

2

Strongly Agree

3

4

We’d like to understand your perceptions of mental health seeking. Please respond to each
of the following using the scale provided. Select the number that best represents what you
think.
Strongly
Disagree

Disagree

No
Opinion

Agree

Personally:
9. I think that it is a sign of personal
weakness or inadequacy to receive
treatment for suicidal thoughts and
behaviors.
10. I would see a person in a less favorable
way if I came to know that he/she has
received treatment for suicidal thoughts
and behaviors.
11. I think that it is advisable for a person
to hide from people that he/she has been
treated for suicidal thoughts and behaviors.
*Adapted from Komiya, Good & Sherrod (2000)

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Strongly
Agree

SPEAKS-S

Now, we’d like to understand the perceptions of mental health seeking on your campus
overall. Please respond to each of the following using the scale provided. Select the number
that best represents what you believe most people on your campus think.

On my campus:

Strongly
Disagree

Disagree

No
Opinion

Agree

Strongly
Agree

12. It is considered a sign of personal
weakness or inadequacy to receive
treatment for suicidal thoughts and
behaviors.
13. People would see a person in a less
favorable way if I came to know that he/she
has received treatment for suicidal thoughts
and behaviors.
14. It is advisable for a person to hide from
people that he/she has been treated for
suicidal thoughts and behaviors.
*Adapted from Komiya, Good & Sherrod (2000)

The following statements represent myths or facts about suicide. Some are true and some
are false. Please indicate whether you believe the statement is true or false (select one).
True False Don’t
Know
15. Most of the time people attempt suicide without warning and out of
the blue.
16. People who have attempted suicide in the past are less likely to
attempt suicide again in the future.
17. Sometimes a minor event (like a bad exam grade) can push an
otherwise normal person to attempt suicide.
18. People who are depressed are more likely to attempt suicide.
19. The great majority of people who commit suicide do not have
psychiatric or substance use disorders.
20. Someone who has aggressive or impulsive tendencies is at lower risk
for suicide attempt.
21. If a person attempted suicide, their situation was probably so bad
that death was the best solution.
22. Reducing access to firearms and other lethal means reduces the risk
of suicide.
23. People who talk about or threaten suicide don’t do it.
24. If someone is exposed to a suicide (family, friends, other students),
this may increase their own risk for attempting suicide.
25. People who really want to die will find a way; it won’t help to try
and stop them.
26. People who are using alcohol more than usual or abusing substances
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SPEAKS-S

True False Don’t
Know
are at greater risk for attempting suicide.
27. A person with a family history of suicide is at lower risk for
attempting suicide.
28. Hopelessness is a risk factor for attempting suicide.
29. You should not talk to depressed people about suicide; it might give
them the idea or plants the seed in their minds.
30. A fellow student with sleep problems is at increased risk for
attempting suicide.
31. People with both mental health problems and substance problems
are at even greater risk of attempting suicide that those with either
mental health or substance problems alone.
32. Suicides are more likely to occur around the holidays like
Thanksgiving and Christmas.
33. Social isolation/withdrawal is a risk factor for suicide attempt.
34. Most suicidal people never discuss their problems with others.
35. The experience of physical, sexual and/or emotional abuse puts one
at greater risk for attempting suicide.
36. A fellow student who has a sexual identity conflict or is uncertain
about their sexual identity is at greater risk for a suicide attempt.
37. Many people who talk about suicide just want attention.
38. Suicide is the leading cause of death among college students.
39. Risk for suicide attempt is not associated with legal problems or
criminal justice involvement (arrest or incarceration).
We’d like to know a little bit about your involvement with and your connectedness to your
campus. Please rate your agreement with the following statements from strongly disagree to
strongly agree.
Strongly Disagree
Disagree

Neither
Disagree or
Agree

Agree

Strongly
Agree

40. I am involved in
extracurricular activities on
campus  
41. I feel I have a supportive
goup of friends on campus  
42. I feel I have a sense of
togetherness with my peers.
43. I feel connected to my
campus.
Adapted from the Social Connectedness Scale. (Lee, R.M., & Robbins, S.B. (1995). Measuring belongingness: The
Social Connectedness and Social Assurance Scales. Journal of Counseling Psychology, 45, 338-345.

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SPEAKS-S

Now we’d like to understand what you do when you encounter a stressful life event. For the
following items, please indicate how often you do the following when you experience a
stressful event: (Please mark the appropriate column for each row) 
44. When I experience a stressful
event:
a. I concentrate my efforts on doing
something about it.  
b. I get emotional support from
others.  
c. I turn to work or other activities
to take my mind off things. 
d. I use alcohol or drugs to make
myself feel better.  
e. I learn to live with it.  
f. I make fun of the situation.  
g. I pray or meditate.  
h. I get help or advice from other
people.  
i. I do things to think about it less
such as going to movies, watch TV,
read, daydream, sleep, or go
shopping.  
j. I give up attempting to cope.  
k. I blame myself.  

Never

Occasionally

Sometimes

Always

Adapted from the Brief COPE. (Carver, C.S. (1997). You want to measure coping but your protocol’s too tong:
Consider the Brief Cope. International Journal of Behavioral Medicine, 4(1), 92-100.)

If you were having a personal or emotional problem, how likely or unlikely is it that you
would seek help from the following people:
45. If I had a personal or
emotional problem I would seek
help from:
a. Intimate partner
(NOTE: If you do not have an
intimate partner, please skip
this item but answer the rest.)
b. Friend not related to you
c. Parent
d. Other relative/family member
e. Mental health
professional/school counselor
f. Doctor/general practitioner
g. Clergy member
h. Other not listed (please
specify)
i. I would not seek help from
anyone

Very
Unlikely

Unlikely

Neither

Suicide Prevention Exposure, Awareness and Knowledge Survey (SPEAKS-S)
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Likely

Very
Likely

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SPEAKS-S

If you were having thoughts of suicide, how likely or unlikely is it that you would seek help
from the following people:
46. If I were having suicidal
thoughts, I would seek help from:

Very
Unlikely

Unlikely

Neither

Likely

Very
Likely

a. Intimate partner
(NOTE: If you do not have an
intimate partner, please skip
this item but answer the rest.)
b. Friend not related to you
c. Parent
d. Other relative/family member
e. Mental health
professional/school counselor
f. Doctor/general practitioner
g. Clergy member
h. Other not listed (please
specify)
i. I would not seek help from
anyone
Adapted from the General Help-Seeking Questionnaire. (Ciarrochi, J.V., & Deane, F.P. (2001). Emotional
competence and willingness to seek help from professional and nonprofessional sources. British Journal of
Guidance & Counseling, 29 ( 2), 233-246

47. Do you know where to find the counseling center on your campus?
 Yes
 No
My campus does not have a counseling center
48. Have you ever received psychological or mental health services from your current
college/university's Counseling or Health Service?



Yes
No
My campus does not have a counseling center

48a. If so, how helpful were the services you received based on why you attended
services?
Very Unhelpful
Unhelpful
Neither
Helpful
Very Helpful
49. Do you know other students who have received psychological or mental health services
from current college/university's Counseling or Health Service?



Yes
No
My campus does not have a counseling center
From the American College Health Association National College Health Assessment, (proposed pilot items), 2007.

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SPEAKS-S

Background Information
50.

What is your gender (select one)?
 Female
 Male
51. What is your age?

years

52. Are you Hispanic or Latino (select one)?
 Yes
 No
52a.

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
 Other Hispanic origin (please describe:_______________________)

53. 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
54. Are you an international student?
Yes
No
55. Which of the following best describes your academic level (select one)?

Undergraduate –1st Year
 Undergraduate –2nd Year
 Undergraduate –3rd Year
 Undergraduate – 4th Year or more
 Graduate Student (e.g., master’s, PhD, MD, JD, DDS, etc.)
55a. Which best describes your enrollment status at this school?
 Part-time
 Full-time
56. Which best describes your living situation?
On-campus, university housing
Off-campus, university housing
Off-campus, non-university housing
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SPEAKS-S

57. How many years have you attended school at this campus? (select one)

One year or less
 More than one year but less than two years
 Between two and three years
 More than three years
Thank you for your time and attention to this survey, the information you have provided is
extremely important to suicide prevention efforts on your Campus.

To request additional information or if you or someone
you know is in need of help,
See A Mental Health Professional on Your Campus
or in Your Community
OR
Dial 1-800-273-TALK (8255)

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Document H.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 .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) Campus Suicide Prevention Program

CAMPUS KEY INFORMANT INFRASTRUCTURE INTERVIEW
(CIFI)

Date: (Today’s Date) //
Site: (Name of Campus) ____________________ [Select from Pull-down menu]
Participant ID: 
Interviewer:

__________________________[Select from Pull-down menu]

Verbal consent provided:

1=yes
2= no

Instructions for interviewer: When to Use: This qualitative interview will be conducted with an
identified representative of the campus: an administrator, human services faculty, non-human
services faculty, representative of the Counseling Center (if applicable), or a student. The local
evaluator will be responsible for developing a potential respondent list from which the target

Campus Infrastructure Interview

respondent will be selected. The questions in this interview are designed to obtain information
about: the campus infrastructure and knowledge base around suicide prevention and related
efforts. Administered by: Staff from the ICF Macro cross-site evaluation team. Completed by: An
administrator, human services faculty, non-human services faculty, representative of the
Counseling Center (if applicable), or a student.

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Campus Infrastructure Interview

Introduction:
Just to remind you, this is an interview designed to understand your knowledge of the Garrett
Lee Smith suicide prevention program as well as your campuses’ approach to student and mental
health. This survey is administered at the end of the first and third year of the grant period, so
please don’t worry if you do not know the answer to all the questions. We are asking the same
questions across X campuses nationwide.
I will ask several questions that will ask you to rank several questions. These will ask about
program effectiveness, campus support for suicide prevention, and the likelihood of several
possible events. These questions are all on a four point scale with No Opinion as an option; for
example, Very supportive, supportive, unsupportive, very unsupportive, and No Opinion.
1) Now just to start were you aware of this award prior to our request for an interview?
•

INTERVIEWER: Yes or no, continue with the survey.

Background:
2) Prepopulated ENA information will appear in Access
•

Rural/urban, size, commuter/residential

•

For purposes of ice-breaker, could review information with respondent: “Towson
University is a small, commuter college in Maryland correct?”

Alright, so the next couple sections of the interview will ask about your knowledge of the grant,
its goals, and your campus’s approach to student health, wellness, and mental health.

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Campus Infrastructure Interview

Reason for Grant and Prior Approach:
1) In your opinion, why did ______________ apply for a GLS suicide prevention
grant?
2) Thinking about your campus before the GLS suicide prevention program do you
recall any suicide prevention activities on campus?
•

PROBE: Outreach and awareness activities, training events

3) Was there a formal plan or policy that described the previous approach?
•

PROBE: Any policies or protocols for dealing with a student in crisis or a campuswide suicide prevention plan?

•

Second administration does not include questions 1-3 if same respondent as first
administration

Awareness of GLS Grant and Goals:
4) To your knowledge, what are the primary, or main goals of the suicide prevention
grant program?
5) Are you aware of any protocols or policies around suicide prevention that are in
development or that the grant program plans to develop?
•

INTERVIEWER: Allow respondent to answer and then use probes.

•

PROBE: This could be a campus-wide plan for suicide prevention, a set response to
crisis or a suicide attempt, training for resident assistants, or a protocol for referring
and treating a student at-risk for suicide.

•

To your knowledge, could you describe any policies or protocols around suicide
prevention developed through the grant?

•

PROBE: This could be a campus-wide plan for suicide prevention, a set response
to crisis or a suicide attempt, or a protocol for referring and treating a student
at-risk for suicide.

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Campus Infrastructure Interview

Campus Approach to Student Health, Wellness, and Mental Health
6)

On your campus, does it seem like mental health is valued as part of general
wellness and student well-being?
PROBE: IF YES, but no explanation: Where have you seen mental health treated
as a part of general wellness and student health?
PROBE: IF NO: Why do you think that mental health is not valued?
o For example, reluctance to discuss mental health, financial considerations, the
campus does not consider mental health to be an academic institution’s
priority
PROBE YES OR NO: Do you expect that the way that mental health is
perceived on campus will change with the grant? Why or why not?
• Second administration: Ask question six and Yes/No probe. Then use following
probe about change over the past three years.
• Have you seen this change over the past three years?
PROBE: Would you describe any changes that have you seen on campus?

7)

Do you agree that the grant has the administrative support that it needs to
accomplish its goals? Strongly agree, agree, disagree, strongly disagree, or No
Opinion. Very supportive, supportive, unsupportive, very unsupportive, and No
Opinion
INTERVIEWER: Could you provide any examples of this support/lack of support?
o Possible cuts/hires of Counseling Center staff, Support from administration,
mention of mental health during orientation or in handbook

Program activities:
I am now going to ask you about the activities that have been sponsored by the suicide
prevention program to accomplish its goals.
8) Ok, could you please describe any efforts, such as trainings or seminars that have
been implemented on campus to educate faculty, staff, and students on suicide
prevention?
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Campus Infrastructure Interview

•

PROBE: Did you participate in these activities?

•

Interviewer: If it is not clear ask the respondent to describe the main points, topics,
and name of the training/activities (such as mental health, identification and referral)

•

Second administration if same respondent: Preface question with, “Since we last
talked…”

9) To your knowledge, is the intended the audience of the education activities the
entire campus community, or is it focused specifically on students, staff, or faculty?
•

PROBE: Are any special groups selected within the campus?
o First year students, graduate students, resident hall students, first-year
faculty/staff

•

PROBE: Are there different messages for different groups?

10) Are there any other activities on campus that are trying to raise awareness about
suicide prevention?
•

FOLLOW UP: For example, wellness or health fairs, depression screenings, or
orientation events?

•

FOLLOW UP: How are these connected to the suicide prevention program?

11) Have you seen any materials, like emails, websites, brochures, stickers, or posters
that are designed to raise awareness about suicide and its prevention?
•

PROBE: Could you describe those materials?

12) Thinking about the educational and awareness efforts that you are aware of, how
effective or ineffective has the program been in increasing knowledge and awareness
of suicide and its prevention on campus? Very effective, effective, ineffective, very
ineffective, and No Opinion
•

PROBE: What makes you feel this way? How have you seen this improvement on
campus?

13) Can you think of some ways that the program’s activities or effectiveness on
campus could be improved?

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Campus Infrastructure Interview

Collaboration and Campus Involvement
This next session of the interview asks about departmental collaboration around suicide
prevention at ________________.
14) What mental health services are available on campus?
•

PROBE: Are there any barriers to access these services?

15) Is there a campus alert team, or a group of individuals that meet to discuss at-risk
students?
•

PROBE: What are the responsibilities of the committee?

•

PROBE: Could you describe the team members, their positions or how often they
meet?

16) Does the grant have an advisory committee?
•

PROBE: What are the responsibilities of the committee?

•

PROBE: Could you describe the team members, their positions or how often they
meet?

17) What departments, offices, and organizations have been involved with the SP
program at ________________?
o What about academic departments?
ƒ

PROBE: Which departments are involved? Have some been more
involved than others?

o Are non-academic departments involved?
ƒ

PROBE: campus staff, clergy, police, athletic or custodial staff?

o What about student organizations?
ƒ

PROBE: Has the program targeted any particular students, for
example Resident Assistants or student government? Any other groups
of students?

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Campus Infrastructure Interview

ƒ

For example: NAMI, Psychology Club/Graduates Students, Active
Minds, Student Council from specific schools (engineering, liberal
arts, etc

18) Has the SP program worked with any off-campus community or health partners to
increase knowledge and awareness?
19) Of all the departments you’ve mentioned, which are the most involved in the suicide
prevention program at ___________?
o Interviewer: If the respondent is unsure, list back departments that the
respondent has discussed.
•

Second administration all respondents: Would you agree that campus
collaboration around suicide prevention has improved over the last three years?
Strongly agree, agree, disagree, strongly disagree, No opinion

Knowledge and Program Outcomes:
20) If, in the course of a conversation with a student/friend, you became concerned that
they were at risk for suicide, what would you do?
•

Do you think that most faculty and staff on campus would know what to do? What
about students?
o PROBE: What other resources are you aware of for referral?

We´re coming to the end of the interview and I want to shift our conversation to talk about
the primary accomplishments and outcomes of the program.
21) Thinking about what the program has accomplished thus far, what would you
identify as the program’s main impact on campus?
•

PROBE: Increased awareness, increased knowledge of suicide prevention and
campus resources

•

To your mind, are there any other changes on campus that you would attribute to the
grant?

22) In your opinion, do you think that the program will be able to accomplish its goals?
Very likely, likely, unlikely, very unlikely, No Opinion
•

Why do you feel this way?

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• Second administration both respondents: In your opinion, do you think that
the program has accomplished its goals? (Completely accomplished, somewhat
accomplished, somewhat unaccomplished, completely unaccomplished, No
opinion)
•

Why do you feel this way?

Sustainability/Most important
23) Of all the suicide prevention activities we have discussed, which do you think is the
most important to continue in the future?
•

PROBE: Why do you choose this particular item?

24) Thinking about sustainability, what would need to happen to continue the suicide
prevention program after the grant period?
•

Staffing, money? Are these resources available?

Recommendations and Barriers/Facilitators:
25) Do you have any final recommendations for how the suicide prevention program
could be improved?
•

INTERVIEWER: When you ask this question, repeat back to the respondent any
recommendations they have already mentioned

INTERVIEWER: Review your notes for facilitators/barriers mentioned in the course of
the interview.
I have two final questions, about the factors that promote and the things that are barriers
to suicide prevention on campus.
26) What do you consider to be the biggest barriers or obstacles to suicide prevention
on campus?
•

FOLLOW UP: How could these barriers be overcome?

•

INTERVIEWER: Have the respondent try to give a response to each barrier.

27) On the opposite side, what are the greatest facilitators of suicide prevention efforts
on campus?

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