Form PSI Campus PSI Campus PSI Campus

OMB No. xxxx-xxxx

Expiration Date: Month XX, XXXX

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 3 hours 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation
Campus Suicide Prevention Program

Prevention Strategies Inventory (PSI)

OUTREACH AND AWARENESS

Public Awareness Campaigns

Public Awareness Campaigns are organized systematic efforts using multiple communications media to make the general public or a particular target population aware of key messages about suicide prevention.

*Please note: campaigns that are specific to means restriction should be reported under “Means Restriction Awareness Campaigns.”

Examples of Public Awareness Campaigns are: the “Be Well to Do Well (BW2DW)” mental health awareness campaign; the “I Am Not a Bystander” campaign; the “How YOU Doin’” campaign; the “Suicide Shouldn't Be a Secret” campaign; the “Ask, Listen, Refer” campaign; and the “Don't Erase Your Future” campaign.

Outreach and Awareness Activities/Events

These are activities and events intended to promote awareness about suicide prevention and are not connected to a particular public awareness campaign.

*Please note: activities/events specific to means restriction should be reported under “Means Restriction Activities and Events.”

Examples of Outreach and Awareness Activities/Events are: a suicide prevention poster contest, an “Out of Darkness” walk, a booth at a health fair, suicide awareness day, and events held during National Red Ribbon Week.

Outreach and Awareness Products

These are products intended to promote awareness about suicide prevention. Their distribution is not limited to or connected to a particular public awareness campaign or to a particular activity/event.

*Please note: products specific to means restriction should be reported under “Means Restriction Products.”

Examples of Outreach and Awareness Products are: radio and TV Public Service Announcements; Website development or enhancement; newspaper articles; billboards; and awareness products such as stress balls, mood pens, T-shirts and bracelets.

GATEKEEPER TRAINING

Gatekeeper Training

Gatekeeper training programs are trainings designed to help students, faculty, staff, and others identify individuals at risk for suicide and to refer them for help.

ASSESSMENT, CLINICAL, AND REFERRAL TRAINING

For Mental Health Professionals

This category refers to training mental health professionals on assessing, managing, and treating suicide risk and making appropriate referrals. Examples of these types of trainings are: Assessing and Managing Suicide Risk (AMSR) for mental health professionals and training clinicians in suicide assessment.

For Hotline Staff

This category refers to training hotline staff in suicide risk assessment and referral skills. These trainings are generally gatekeeper training, but must have the specific goal of training those who will be staffing a hotline or helpline.

LIFE SKILLS AND WELLNESS development

Life Skills and Wellness Activities

These activities include workshops, educational seminars, speaking events, and trainings that provide students with essential life skills and promote wellness. These activities intend to support positive social, emotional, spiritual, and academic development.

Examples of Life Skills and Wellness Activities are: workshops on stress management or healthy relationships; seminars on depression, anxiety, eating disorders and body image; tai chi; yoga; meditation; progressive muscle relaxation; and dance and movement.

Cultural Activities

These are activities that use a “culture as prevention” approach and are intended to strengthen the ties students feel with both the campus community and their own cultural group.

Examples of Cultural Activities include: culturally based support groups, culturally based student groups, or suicide prevention activities that tie into cultural beliefs and practices.

SCREENING PROGRAMS

Early Identification Screening Programs involve the administration of a screening instrument or an online mental health screening tool to identify at-risk youth.

Examples of Screening Programs include: Depression Screening, ISP, other online screening tools.

HOTLINES, HELPLINES, Textlines, and chatlines

Hotlines and Helplines

Developing, maintaining or supporting hotline or helpline services for the campus community.

A grantee may use GLS funds to develop and maintain a hotline service for students or a grantee can use funds to develop a local call center for the National Suicide Prevention Hotline.

*Please note: training for hotline staff should be indicated under “Assessment and Referral Training for Hotline Staff.” Also, materials promoting the National Suicide Prevention Lifeline should be reported under “Outreach and Awareness Products.”

Textlines and Chatlines

Developing, maintaining, or supporting text or web-based chat support services for the campus community.

*Please note: training for text and chat staff should be indicated under “Assessment and Referral Training for Hotline Staff” and materials promoting the textline, chatline, or National Suicide Prevention Lifeline should be reported under “Outreach and Awareness Products.”

MEANS RESTRICTION

Means Restriction are efforts that aim to educate about the issue of lethal means restriction. Examples of efforts that would be reported under this category include: a campaign dedicated to reducing access to lethal means, and outreach and awareness events, activities and materials focused on issues related to access to lethal means.

Means Restriction Awareness Campaigns

A Means Public Awareness Campaign is an organized systematic effort through various communications media focused on creating awareness about access to lethal means among the general public or particular target populations. For example: the “Lock ‘Em Up” Prescription Drug Campaign.

Means Restriction Activities and Events

Events or activities intended to promote awareness about access to lethal means but not connected to a particular public awareness campaign.

Means Restriction Products

Products intended to promote awareness about access to lethal means and not connected to a particular public awareness campaign.

Examples of these types of products are: radio and TV Public Service Announcements, Website development or enhancement, newspaper articles, brochures, billboards, and awareness products such as stress balls, mood pens, T-shirts, and bracelets.

Means Restriction Training

Training designed to teach behavioral health professionals to counsel the families of those at-risk for suicide in methods to reduce access to lethal means.

POLICIES, PROTOCOLS, AND INFRASTRUCTURE

These are policies and protocols utilized by a special team formed to respond to students at risk or to crisis situations, and involve various individuals, agencies and services, including campus departments, mental health centers, hospitals, mobile crisis teams, police, parents/guardians, etc. Polices and protocols are formally written statements documenting the procedures to be followed. This strategy also includes infrastructure development related to the utilization of electronic health records to enhance suicide prevention efforts.

Policies and Protocols Related to Intervention

Policies and protocols related to intervention guide the actions of all agencies and personnel involved in ensuring that at-risk students receive coordinated, timely and effective assessment, referral, treatment, and follow-up support.

Policies and Protocols Related to Postvention

Policies and protocols related to postvention guide the actions of all campus departments and personnel and outside agencies involved in taking appropriate postvention steps to support family, friends, and the campus community following a suicide, and to prevent cluster suicides.

Electronic Health Record Implementation and Utilization

The implementation or utilization of electronic health records to align with suicide prevention efforts, such as tracking follow up services or referrals, enhancing communications, or improving surveillance.

COALITIONS AND PARTNERSHIPS

The leading, support, or participation of agencies, programs or organizations in suicide prevention or other prevention coalitions are examples of this activity. This category also includes partnerships that result in coordinated services or activities.

Leading or Substantially Supporting a Suicide Prevention Coalition

The development of a means for cooperation and collaboration among persons, groups, or organizations to work together toward goals related to suicide prevention.

Leading or Substantially Supporting a Coalition That Is Closely Related To Youth Suicide Prevention

The development of a structured arrangement for cooperation and collaboration among persons, groups, or organizations, in order to work together toward goals related to youth prevention (e.g., youth violence, substance abuse) or the promotion of health and well-being.

Participating In Coalitions Related To Prevention

Participation in or support of coalitions related to prevention efforts (e.g., youth violence, domestic violence, or substance abuse) or the promotion of mental health and well-being.

Partnerships with Agencies And Organizations

Efforts to build partnerships to facilitate timely, effective and coordinated suicide prevention and early identification. These partnerships will generally involve a memorandum of understanding or other formal agreement.

OTHER SUICIDE PREVENTION STRATEGIES

Prevention strategies that cannot be classified under the previously listed strategy types can go under “Other.” Items that are commonly reported in this strategy include: other trainings (e.g., cultural competence/SafeZone trainings), congressional testimony, postvention activities or products, or work to make suicide prevention education part of a course curriculum or degree requirement.

OUTREACH AND AWARENESS

Public Awareness Campaigns

1. What is the name of the public awareness campaign?

2. Please describe the public awareness campaign. Include information such as goals, methods/elements and intended audiences.

3. Does this strategy target the entire campus community?

• Yes [Go to Q. 6]

• No [Continue with Q.5]

4. If no, please indicate the populations targeted by the public awareness campaign. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-campus community member (including family member)

• Other, please specify __________

5. Does your campaign place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

6. Please indicate which of the following elements are used in this public awareness campaign, and for each selected element, please provide a brief description.

• Print materials such as brochures, posters and flyers. Please describe: ____________

• Print media such as newspapers/magazines/newsletters. Please describe: ____________

• Billboards. Please describe: ____________

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.)

• Please describe: ____________

• Web site development/enhancement. Please describe: ____________

• Social media (Facebook,Twitter, Instagram, etc.). Please describe: ________

• Radio. Please describe: ____________

• TV. Please describe: ____________

• DVD. Please describe: ____________

• Events/activities. Please describe: ____________

• Booth at health fair. Please describe: __________

• Other. Please describe: ________

Outreach and Awareness Activities and Events

1. What is the name of activity/event?

2. Type of activity/event

• Participation in a Health Fair (ex. Booth or table)

• Awareness walk (ex. Out of Darkness)

• Poster contest

• Awareness/informational presentation

• Other, please specify: __________________

3. Please describe the activity or event. Explain how the activity or event relates to the goals of your suicide prevention program.

4. Does this strategy target the entire campus community?

• Yes [Go to Q. 7]

• No [Continue with Q.6]

5. If no, please indicate the populations targeted by the activity or event. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-campus community member (including family member)

• Other, please specify: __________

6. Does this activity/event place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

Outreach and Awareness Products

1. What is the name of the product?

2. Type of product

• Print materials such as brochures, posters and flyers

• Print media such as newspapers/magazines/newsletters

• Billboards

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.,)

• Mobile applications

• Website development/enhancement

• Social Media (Facebook, Twitter, Instagram, etc.)

• Radio

• TV

• DVD

• Other, please specify: ___________________

3. Please describe the product. Explain how this product relates to the goals of your suicide prevention program.

4. Does this strategy target the entire campus community?

• Yes [Go to Q.7]

• No [Continue to Q.6]

5. If no, please indicate the populations targeted by the product. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-campus community member (including family member)

• Other, please specify __________

6. Does this product place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

Gatekeeper Training

1. What is the name of the training?

2. Please indicate the type of training:

• QPR (Question, Persuade, Refer)

• Yellow Ribbon

• ASIST (Applied Suicide Intervention Skills Training)

• Signs of Suicide (SOS)

• Sources of Strength

• SafeTALK

• Lifelines

• Campus Connect

• Kognito At-Risk

• Other, please specify: _______________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Were the trainees members of the entire campus community?

• Yes [Go to Q.6]

• No [Continue to Q.5]

4. If no, please indicate the types of trainees. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-campus community member (including family member)

• Other, please specify __________

5. Does this training place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

6. Please describe the training. If you are using a standard curriculum (one of the types mentioned in Q2), you need not describe the content of the curriculum. . If you are using a locally developed curriculum, please also describe the content of the curriculum. Provide description such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc.

7. How do you monitor or track students after referral to ensure follow-up services (mental health or other support services) are received?

• Student information is entered into an electronic database; electronic alerts at specified follow-up intervals

• Trainee responsible for tracking and monitoring follow-up

• Campus administration responsible for tracking and monitoring follow up

• Care coordinator responsible for tracking and monitoring follow up

• Other process, please describe ________________________________________

8. What practices or protocols are in place to follow-up with students who do not receive a mental health service (or other support services) within three months of referral?

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Campus administration follows up with youth to determine why services have not been received

• Campus administration follows up with parent/guardian to determine why services have not been received

• Students are flagged in an electronic database and an alert is provided at weekly (or some other) intervals for follow-up

• Care coordinator responsible for monitoring/tracking follow up

• Other process, please describe _____________________________

assessment, Clinical, and referral Training for mental health professionals AND HOTLINE STAFF

Mental Health Professionals

1. What is the name of the training?

2. Please indicate the type of training:

• AMSR (Assessing and Managing Suicide Risk)

• RRSR (Recognizing and Responding to Suicide Risk)

• Cognitive Behavioral Theapy (CBT)
  Chronological Assessment of Suicide Events (CASE)

• Dialectical Behavior Therapy (DBT)

• Kognito At-Risk in Primary Care

• Kognito At-Risk in the ED

• Mental Health First Aid

• QPR for Nurses

• QPR for Physicians, Physician Assistants, Nurse Practitioners, and Others

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please indicate the types of trainees.

• Mental health clinician/counselor/ psychologist

• Social Worker/Caseworker / Care coordinator

• Other, please specify: ____________

4. Please describe the training. If you are using a standard curriculum (one of the types mentioned in Q2), you need not describe the content of the curriculum. . If you are using a locally developed curriculum, please also describe the content of the curriculum. Provide description such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc

5. How do you monitor or track students after referral to ensure follow-up services (mental health or other support services) are received?

• Student information is entered into an electronic database; electronic alerts at specified follow-up intervals

• Trainee responsible for tracking and monitoring follow-up

• Campus administration responsible for tracking and monitoring follow up

• Care coordinator responsible for tracking and monitoring follow up

• Other process, please describe ________________________________________

6. What practices or protocols are in place to follow-up with students who do not receive a mental health service (or other support services) within three months of referral?

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Campus administration follows up with youth to determine why services have not been received

• Campus administration follows up with parent/guardian to determine why services have not been received

• Students are flagged in an electronic database and an alert is provided at weekly (or some other) intervals for follow-up

• Care coordinator responsible for monitoring/tracking follow up

• Other process, please describe _____________________________

Hotline Staff

1. What is the name of the training?

2. Please indicate the type of training:

• QPR (Question, Persuade, Refer)

• ASIST (Applied Suicide Intervention Skills Training)

• SafeTALK

• Campus Connect

• Lifelines

• Signs of Suicide

• Other, please specify: _______________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please indicate the types of trainees.

• Mental health clinician/counselor/psychologist

• Social worker/caseworker/care coordinator

• Volunteers

• Other, please specify: ____________

4. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

LIFE SKILLS AND WELLNESS development

Life Skills and Wellness Activities

1. What is the name of the activity?

2. Please describe the activity. Include its purpose and how it relates to suicide prevention efforts.

3. Does this life skills/wellness activity place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

Cultural Activities

1. What is the name of the activity?

2. Please describe the activity. Include its purpose and how it relates to suicide prevention efforts.

3. Does this cultural activity place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

SCREENING PROGRAMS

1. What is the name of the screening program?

2. Please indicate the type of screening tool:

• Patient Health Questionnaire (PHQ-9)

• Suicide Assessment Five Step Evaluation and Triage (SAFE-T)

• Columbia Suicide Severity Rating Scale (CSSR-S)

• Behavioral Health Screen (BHS)

• Ask Suicide Screening Questions (asQ)

• Beck Depression Inventory (BDI)

• Suicide Behaviors Questionnaire (SBQ-R)

• Locally Developed Screening Tool

• Other Screening Tool, please specify:___________________

3. Please describe the screening program.

4. Please indicate the settings targeted by the screening program. Select all that apply.

• Online

• At the counseling center

• At a health fair

• On-campus medical center (Health Center)

• At awareness events such as National Depression Screening Day

• In class

5. What procedures or processes are in place to ensure that students, identified at-risk through this screening tool, receive follow-up services within three months of referral?

• Screener follows up with student to determine if services have been received

• Screener follows up with parent/guardian of student to determine if services have been received

• Screener follows up with referral to determine if services have been received

• Students are flagged in an electronic database and an alert is provided at weekly intervals (or some other interval) for follow up

• Care coordinator responsible for tracking and monitoring follow up

• Other process, please describe_____________________________

6. How do you monitor or track students after referral to ensure follow-up services (mental health or other support services) are received?

• Student information is entered into an electronic database; electronic alerts at specified follow-up intervals

• Screener responsible for tracking and monitoring follow-up

• Campus administration responsible for tracking and monitoring follow-up

• Care coordinator responsible for tracking/monitoring follow up

• Other process, please describe __________________________

7. What practices or protocols are in place to follow-up with students who do not receive a mental health service (or other support service) within three months of referral?

• Screener follows up with student to determine why services have not been received

• Screener follows up with parent/guardian to determine why services have not been received

• Campus administration follows up with youth to determine why services have not been received

• Campus administration follows up with parent/guardian to determine why services have not been received

• Students are flagged in an electronic database and an alert is provided at weekly intervals (or some other interval) for follow-up

• Care coordinator responsible for tracking and monitoring follow up

• Other process, please describe ____________________

HOTLINES AND HELPLINES

Hotlines and Helplines

1. What is the name of the hotline/helpline?

2. Please describe the hotline/helpline. Include information such as: whether it is locally developed or supported by the National Suicide Prevention Lifeline; its hours of operation; whether it is available to the entire community, etc.

3. Please indicate the populations targeted by the crisis hotline/helpline (geographic scope, demographics etc,).

Textlines and Chatlines

1. What is the name of the text/chat line?

2. Please describe the textline/chatline. Include information such as: whether it is locally developed or supported by the National Suicide Prevention Lifeline; its hours of operation; whether it is available to the entire community, etc.

3. Please indicate the populations targeted by the crisis textline/chatline (geographic scope, demographics etc.).

Means Restriction

Means Restriction Awareness Campaign

1. What is the name of the means restriction awareness campaign?

2. Please describe the means restriction awareness campaign—its goals, methods/elements and intended audiences.

3. Does this strategy target the entire campus community?

• Yes [Go to Q.6]

• No [Continue to Q.5]

4. If no, please indicate the populations targeted by the means restriction awareness campaign. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-campus community member (including family member)

• Other, please specify __________

5. Does this means restriction awareness campaign place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

6. Please indicate which of the following elements are used in this public awareness campaign, and for each selected element, please provide a brief description.

• Print materials such as brochures, posters and flyers. Please describe: ___________

• Print media such as newspapers/magazines/newsletters. Please describe: ____________

• Billboards. Please describe: ____________

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.) Please describe: ____________

• Website development/enhancement. Please describe: ____________

• Social media (Facebook, Twitter, Instagram, etc.). Please describe: ____________

• Radio. Please describe: ____________

• TV. Please describe: ____________

• DVD. Please describe: ____________

• Events/activities. Please describe: ____________

• Booth at health fair. Please describe: ____________

• Other, please describe: ____________

Activities and Events

1. What is the name of the means restriction activity/event?

2. Type of means restriction activity/event

• Participation in a Health Fair (ex. Booth or table)

• Poster contest

• Awareness/informational presentation

• Other, please specify: __________________

3. Please describe the means restriction activity or event. Explain how the activity or event relates to the goals of your suicide prevention program.

4. Does this strategy target the entire campus community?

• Yes [Go to Q.7]

• No [Continue to Q.6]

5. If no, please indicate the populations targeted by the means restriction activity or event. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-Campus community member (including family member)

• Other, please specify: __________

6. Does this means restriction activity or event place emphasis or focus on any of these current priority populations? Select all that aplly.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

Mean Restriction Products

1. What is the name of the means restriction product?

2. Type of means restriction product

• Print materials such as brochures, posters and flyers

• Print media such as newspapers/magazines/newsletters

• Billboards

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.)

• Mobile Applications

• Website development/enhancement

• Social Media (Facebook, Twitter, Instagram, etc.)

• Radio

• TV

• DVD

• Other, please specify: ___________________

3. Please describe the means restriction product. Explain how this product relates to the goals of your suicide prevention program.

4. Does this strategy target the entire campus community?

• Yes [Go to Q.7]

• No [Continue to Q.6]

5. If no, please indicate the populations targeted by the means restriction product. Select all that apply.

• Undergraduate student

• Graduate student

• Campus administrator

• Campus staff (including mental/primary health care providers)

• Faculty/instructor/lecturer

• Off-campus community member (including family member)

• Other, please specify: __________

6. Does this means restriction product place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

Means Restriction Training

1. What is the name of the training?

2. Please indicate the type of training:

• CALM (Counseling on Access to Lethal Means)

• Other, please specify: _______________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please describe the training. If you are using a standard curriculum, you need not describe the content of the curriculum. . If you are using a locally developed curriculum, please also describe the content of the curriculum. .Provide description such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc.

4. Please indicate the types of trainees:

• Mental Health clinician/counselor/psychologist

• Social Worker/Caseworker/Care coordinator

• Other, please specify: ______________

POLICIES, Protocols, and Infrastructure

Policies and protocols related to Intervention

1. What is the name of the policy/protocol?

2. Please describe the purpose of this policy/protocol? Who is included/involved in the implementation (staff/agencies)? How will this policy/protocol be used and communicated?

Policies and protocols related to Postvention

1. What is the name of the policy/protocol?

2. Please describe the purpose of this policy/protocol? Who is included/involved in the implementation (staff/agencies)? How will this policy/protocol be used and communicated?

Electronic health record implementation and/or utilization

1. Please describe how electronic health records are used to support suicide prevention efforts. Who is included/involved in implementation? In what setting is the electronic health record utilized?

2. In which of the following ways is the electronic health record used to enhance grant activities?

• Suicide screening and risk assessment

• Monitoring progress and follow up of youth after identification

• Communication between multiple providers

• Creating and sharing safety plans with youth and/or families

• Tracking scheduled appointments

• Tracking suicide attempts or deaths

• Other, please specify:

coalitions and partnerships

Leading or Substantially Supporting a Suicide Prevention Coalition

1. What is the name of the coalition?

2. Please provide a brief description of the coalition. Include information such as: what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements and how frequently do the members meet; strategies for sustaining the coalition, etc.

Leading or Substantially Supporting a Coalition That Is Closely Related To Youth Suicide Prevention

1. What is the name of the coalition?

2. Please provide a brief description of the coalition. Include information such as: what types of agencies participate in the coalition; what are the coalition’s goals of the coalition; what are its major achievements; how frequently do the members meet; strategies for sustaining the coalition etc.

Participation in a Coalition Related To Youth Prevention

1. What is the name of the coalition?

2. Please provide a brief description of the coalition. Include information such as: how does your participation in this coalition advance your suicide prevention effort; what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements; and how frequently do the members meet, etc.

Partnerships with agencies and organizations

1. Name of partnership strategy:____________________

2. Please provide a brief description of your efforts to build partnerships with youth-serving agencies and organizations (on-campus and off-campus partnerships).

OTHER SUICIDE PREVENTION STRATEGIES

1. Name of suicide prevention strategy: ________________

2. Type of suicide prevention strategy

• Postvention Products and Activities

• Postvention Training

• Inclusion of suicide prevention content into curriculum/course

• Cultural sensitivity training. Describe group:

• Other training, please describe: ___________________

• Other, please describe: ___________________

3. Please provide a brief description of this suicide prevention strategy. Include elements such as type of strategy, target populations, etc.

4. Does this strategy place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________

BUDGET

How much of your GLS budget, including any matching funds, have you spent to date? Specify dollar amount:

Please estimate the percentage of your total budget expended to date on the following prevention strategies.

[ONLY MAJOR STRATEGIES (BOLD CAPS) ARE REQUIRED.]

OUTREACH AND AWARENESS ___%

Public Awareness Campaigns ___%

Outreach and Awareness Activities and Events ___%

Outreach and Awareness Products ___%

GATEKEEPER TRAINING ___%

ASSESSMENT AND REFERRAL TRAINING ___%

For Mental Health Professionals ___%

For Hotline Staff ___%

LIFE SKILLS AND wellness Development ___%

Life Skills and Wellness Activities ___%

Cultural Activities ___%

SCREENING PROGRAMS ___%

HOTLINES, HELPLINES, Textlines, and chatlines ___%

Hotlines and Helplines ___%

Textlines and Chatlines ___%

MEANS RESTRICTION ___%

Means Restriction Awareness Campaigns ___%

Means Restriction Events ___%

Means Restriction Training ___%

Means Restriction Products ___%

POLICIES, PROTOCOLS, and infrastructure ___%

Policies and protocols related to Intervention ___%

Policies and protocols related to Postvention ___%

Electronic health record implementation/utilization ___%

COALITIONS AND PARTNERSHIPS ___%

Leading or Substantially Supporting a Suicide Prevention Coalition ___%

Leading or Substantially Supporting a Coalition that is Closely Related to Youth Suicide Prevention ___%

Participating in Coalitions Related to Youth Suicide Prevention ___%

Partnerships with Agencies and Organizations ___%

OTHER SUICIDE PREVENTION STRATEGY ___%

Campus Prevention Strategies Inventory (PSI) 1

12/2015