J.1 SAIS Baseline J.1 SAIS Baseline Instrument and Web Consent

OMB No. 0930-0286

Expiration Date: October 2016

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 60 minutes per respondent, 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 2-1057, Rockville, Maryland, 20857.

Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS)

Campus Suicide Prevention Program

Student Awareness Intercept Survey (SAIS)—Baseline

Before you continue with this 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. It is very important that you understand that your participation in this survey is voluntary and that the information you share is private.

Description of Participation

Your school, along with other schools across the country, received federal funding to support the implementation of a Garrett Lee Smith (GLS) Campus Suicide Prevention Program supported by the Substance Abuse and Mental Health Services Administration (SAMHSA). As part of this effort, you are being asked to participate in the Student Awareness Intercept Survey (SAIS) regarding suicide prevention. The survey includes a series of questions asking you about your experiences, behaviors, attitudes, and beliefs related to mental health seeking and suicide prevention as well as your exposure to suicide prevention activities on your campus. The findings from this survey will be used to inform SAMHSA about the impact of suicide prevention activities on campuses, particularly social marketing campaigns.

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. The information that we report to SAMSHA will be reported in aggregate and will not contain any identifying information. Your name will not be used in any reports about this evaluation. Survey data are encrypted on and stored on a secure server.

Risks: Completing this survey poses few, if any, risks to you. Some questions may make you feel uncomfortable. You may choose to stop the survey at any time. You may choose to not answer a question for any reason. There is no penalty or consequence to you. You also can contact the evaluation project director at any time.

Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national effort to prevent suicide on college campuses.

Compensation: You will receive $10 for participating in this survey.

Rights Regarding Decision to Participate: Participation in the survey is completely voluntary. Refusal to participate involves no penalty or adverse consequences. You do not have to answer questions that you do not want to answer. You may choose to discontinue the survey at any time, for any reason.

Contact Information: If you have any concerns about your participation in this survey or have any questions about the evaluation, please contact Christine Walrath, principal investigator, at Christine.Walrath@icfi.com or you may call her directly at 212-941-5555. For survey help, please contact GLS-SAIS@icfi.com.

Please click the “I CONSENT” box below to proceed to the survey.

• “I CONSENT” (Move to next Web page to start the survey.)

• “I DO NOT CONSENT” (Move to the Web page which should say “Thank you for your time in considering participation in the Student Awareness Intercept Survey. Please contact the principal investigator, Christine Walrath, at 212-941-5555 with any questions,” and offer respondents an opportunity to go to the survey homepage.)

Thank you!

Thank you for agreeing to participate in this survey about mental health on college campuses.

1. In the past 12 months, have you talked about [INSERT MAIN SMC MESSAGE HERE (E.G., HOW TO COPE WITH STRESS, RECOGNIZE THE WARNING SIGNS OF DEPRESSION OR SUICIDE)] with any of your friends or fellow students on campus?

• Yes --> Show question 1b (how many times)

• No

• Don’t know

1b. How many times have you discussed [INSERT MAIN SMC MESSAGE HERE (E.G., HOW TO COPE WITH STRESS, RECOGNIZE THE WARNING SIGNS OF DEPRESSION OR SUICIDE)] with your friends or fellow students on campus in the last 12 months?

________

Available Resources and Referral/Use of Services

Next, we would like to know about the resources available to students on campus and their use. Please select the response option that best represents your answer.

2. Are you aware of at least one campus or local resource where you could refer a fellow student or friend who needs mental health services (including how to cope with stress)?

• Yes (continue to question 3)

• No (skip to question 5)

3. In the past 12 months, have you referred a friend or fellow student to [INSERT CAMPUS RESOURCE HERE] (including for services like how to cope with stress?

• Yes (continue to question 4)

• No (skip to question 5)

4. How many fellow students and/or friends have you referred for mental health services (including services like how to cope with stress) in the past 12 months?

Number of individual students _______

5. In the past 12 months, have you personally received services at [INSERT CAMPUS RESOURCE HERE]?

• Yes

• No

6. Please indicate your level of agreement with the following statement:

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree
My campus values the mental health and well-being of its students.	0	1	2	3	4

Mental Health Help-Seeking Attitudes

We would like to understand your perceptions of mental health help-seeking. Using the scale provided, please select the response option that best describes your opinion for each statement.

In my personal opinion:	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree
I think that it is a sign of personal weakness or inadequacy to receive treatment for suicidal thoughts and behaviors.	0	1	2	3	4
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.	0	1	2	3	4
I think that it is advisable for a person to hide from people that he/she has been treated for suicidal thoughts and behaviors.	0	1	2	3	4
I wouldn’t trust someone who received mental health treatment.	0	1	2	3	4

Helping Behaviors

Next, we would like to know about helping others. Please select the response option that best represents your answer.

11. If a friend/fellow student told you he/she was depressed most of the time, what would you do?

	Yes	No	Don’t know
Tell your friend to call a suicide hotline or helpline	¡	¡	¡
Believe your friend/fellow student is serious and try to get him/her to get help	¡	¡	¡
Talk to your friend about what he/she is feeling	¡	¡	¡
Do nothing	¡	¡	¡
Get advice from another student/friend	¡	¡	¡
Talk to a faculty/staff member	¡	¡	¡
Tell the friend/student’s parents	¡	¡	¡
Walk your friend to the INSERT CAMPUS RESOURCE HERE	¡	¡	¡
Laugh it off/assume my friend was joking	¡	¡	¡
Other? Please specify ________________________________________	¡	¡	¡

12. If a friend/fellow student told you he/she was thinking about killing him/herself, what would you do?

	Yes	No	Don’t know
Tell your friend to call a suicide hotline or helpline?	¡	¡	¡
Believe your friend/fellow student is serious and try to get him/her to get help?	¡	¡	¡
Talk to your friend about what he/she is feeling?	¡	¡	¡
Do nothing?	¡	¡	¡
Get advice from another student/friend?	¡	¡	¡
Talk to a faculty/staff member?	¡	¡	¡
Tell the friend/student’s parents?	¡	¡	¡
Walk your friend to the INSERT CAMPUS RESOURCE HERE?	¡	¡	¡
Laugh it off/assume my friend was joking	¡	¡	¡
Other? Please specify _________________________________________	¡	¡	¡

Suicide and Its Prevention

The following statements represent myths or facts about suicide. Some are true and some are false. Please indicate whether you believe each statement is true or false. (Select one.)

	True	False	Don’t know
People often attempt suicide without warning and out of the blue.
People who have attempted suicide are less likely to attempt suicide in the future.
Sometimes a minor event (like a bad exam grade) can push an otherwise normal person to attempt suicide.
People who are depressed are more likely to attempt suicide.
The great majority of people who commit suicide do not have psychiatric or substance use disorders.
Someone who has aggressive or impulsive tendencies is at lower risk for suicide attempt.
If a person attempted suicide, their situation was probably so bad that death was the best solution.
Reducing access to firearms and other lethal weapons reduces the risk of suicide.
People who talk about or threaten suicide don’t do it.
If someone (family, friends, other students) is exposed to a suicide, this increases their own risk for attempting suicide.
People who really want to die will find a way; it won’t help to try and stop them.
People who are using alcohol more than usual or abusing substances are at greater risk for attempting suicide.
A person with a family history of suicide is at lower risk for attempting suicide.
Hopelessness is a risk factor for attempting suicide.
You should not talk to depressed people about suicide; it might give them the idea or plant the seed in their minds.
A fellow student with sleep problems is at increased risk for attempting suicide.
People with both mental health problems and substance abuse problems are at even greater risk of attempting suicide than those with either mental health or substance abuse problems alone.
The majority of suicides are among people of lower socioeconomic status.
Suicides occur in the greatest numbers around the holidays like Thanksgiving and Christmas.
Social isolation/withdrawal is a risk factor for suicide attempt.
Most suicidal people never discuss their problems with others.
The experience of physical, sexual and/or emotional abuse puts one at greater risk for attempting suicide.
A fellow student who has a sexual identity conflict or is uncertain about his/her sexual identity is at greater risk for a suicide attempt.
Many people who talk about suicide just want attention.
Suicide is the leading cause of death among college students.
Risk for suicide attempt is not associated with police or law enforcement (arrest or incarceration) contact.
Most suicide attempts occur late at night or early in the morning.

Next we would like to understand your ability to recognize warning signs/symptoms in others. Please select the response option that best represents your answer.

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree
If my friend/fellow student was depressed, I would recognize it.	0	1	2	3	4
If a friend/fellow student was exhibiting warning signs of suicide, I would recognize it.	0	1	2	3	4

Coping

We would like to understand what you typically do when experiencing a stressful life event. For each statement, please choose the response option that best represents you.

	Never	Occasionally	Sometimes	Always
42. When I experience a stressful event:
I concentrate my efforts on doing something about it.
I get emotional support from others.
I turn to work or other activities to take my mind off things.
I use alcohol or drugs to make myself feel better.
I learn to live with it.
I make fun of the situation.
I pray or meditate.
I get help or advice from other people.
I do things to think about it less such as going to movies, watching TV, reading, daydreaming, sleeping, or going shopping.
I give up attempting to cope.
I blame myself.

If you were having a personal or emotional problem, how likely or unlikely is it that you would seek help from the following people: - ONLY KEEP IF THE SMC IS TIED TO COPING STRATEGIES

	Very unlikely	Unlikely	Neither	Likely	Very likely	N/A Does not apply
43. If I had a personal or emotional problem I would seek help from:
Intimate partner
Friend not related to you
Parent
Other relative/family member
Mental health professional / school counselor
Doctor/general practitioner
Clergy member
Other not listed (please specify)
I would not seek help from anyone.

44. Do you know where to find the counseling center on your campus? – REMOVE IF COUNSELING CENTER IS NOT PRESENT ON CAMPUS

• Yes

• No

• My campus does not have a counseling center.

45. Have you ever received psychological or mental health services from your current college/university's counseling or health services?

• Yes

• No

• My campus does not have a counseling center.

45. Do you know other students who have received psychological or mental health services from your current college/university's counseling or health services?

• Yes

• No

• My campus does not have a counseling center

Next, we would like to ask you questions about suicide. We recognize that some of these questions may be difficult to answer, but your answers are very important to understanding the types of programs, services, and outreach that need to occur with students on your campus. You may skip these questions if you prefer not to answer. To talk with a counselor please call the National Suicide Prevention Lifeline at 1-800-273-8255, 24/7.

45. In the past 12 months, how many times have you thought of killing yourself?

• Never

• Once

• More than once

45. During the past 12 months, did you ever seriously consider attempting suicide?

• Yes

• No

• Skip

45. In the past 12 months, how many times did you actually attempt suicide?

• 0 times

• 1 time

• 2 or 3 times

• 4 or 5 times

• 6 or more times

• Skip

Background Information

45. What is your gender (select one)?

• Female

• Male

• Trans male/Trans man

• Trans female/Trans woman

• Gender nonconforming

• Other, please specify:___________________

45. Do you think of yourself as:

• Heterosexual (that is, straight)

• Gay or lesbian

• Bisexual

• Not sure

45. What is your age? years

45. Are you Hispanic or Latino? (Select one.)

• Yes

• No

1. 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:_______________________)

45. 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

45. Are you an international student?

• Yes

• No

45. Which of the following best describes your academic level? (Select one.)

• Undergraduate –1^st Year

• Undergraduate –2^nd Year

• Undergraduate –3^rd Year

• Undergraduate – 4^th Year or more

• Graduate student—Master degree, PhD, MD, JD, DDS, etc.

45. What best describes your enrollment status at this school?

• Part-time

• Full-time

45. What best describes your living situation?

• On-campus, university housing

• Off-campus, university housing

• Off-campus, non-university housing

45. Are you interested in being contacted for the online follow-up survey in 3 months? You will receive a $10 gift code for your participation.

• YES, I am interested in being contacted for the 3-month online follow-up survey. Note: You will be routed to a new screen to provide consent opt out.

[If yes, send to Consent to Contact Page and then Thank You Page]

• NO, I am not interested in being contacted for the online follow-up survey in 3 months

[If no, send to Thank You page only]

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[Start Consent to Contact Page]

Consent to be Contacted for Follow-up Survey

In approximately 3 months, we will administer a follow-up online survey. We would greatly appreciate your participation at that time. You will be invited to participate by email. Some respondents may receive a telephone call as a reminder to participate before the survey closes.

If you have questions or concerns, please speak to a survey team member onsite now or contact the principal investigator at christine.walrath@icfi.com or 212-941-5555.

Please enter your contact information below and provide consent if you agree to be contacted for the follow-up survey. Your information will be kept private and will never be associated with survey results.

Name
Email Address (best to reach you)
Telephone Number

Please click “I CONSENT” if you agree to be contacted for the follow-up survey.

• I CONSENT

• I DO NOT CONSENT

[Route to Thank You Page Regardless of Response]

[End Consent to Contact Page]

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[Start Thank You Page]

THANK YOU for your time!

Your participation in this survey, along with students on your campus and others, will provide valuable information to Campus and National programs to prevent suicide.

To request additional information or if you or someone you know is in need of help:

Contact [INSERT CAMPUS CAPS NAME/RESOURCE HERE]

OR

Call the NATIONAL SUICIDE PREVENTION LIFELINE to speak to a someone

1-800-273-TALK (8255)

[End Thank You Page]

Student Awareness Intercept Survey (SAIS)—Baseline Page 2

09.24.13