EIRF-Screening For EIRF-Screening Form StateTribal

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

State/Tribal Suicide Prevention Program

Directions: The following information should be completed by a professional to document aggregate information about youths—aged 10–24— who were screened for suicide risk as part of your GLS Suicide Prevention Program. The grantee should complete this form for both group screening events and individual screenings. In the case of individual screenings, the grantee should sum the individual screening information and provide aggregate numbers in the form below on a monthly basis.

As you complete the form, please note that all entries and descriptions of other should not use acronyms or any local terms; please be sure that you only select other when none of the available response options apply and that your descriptions of other be sufficient for someone who is not familiar with your program or community to interpret.

Early Identification, Referral, and Follow-up (EIRF) Screening Form

SECTION 1. SCREENING INFORMATION

1. Name of Grantee: ____________________________________________________________

2. Date of screening

If individual screenings, enter the date of the last screening

Month Day Year

3. Was this a group screening event or individual screenings (i.e., were multiple youths screened at one time as part of a screening event, or was the screening administered to one individual at a time)?

Group Individual

4. What screening tool was used? Select one

• Patient Health Questionnaire (PHQ-9)

• Columbia Suicide Severity Rating Scale (CSSR-S)

• Behavioral Health Screen (BHS)Information Missing

• Ask Suicide Screening Questions (asQ)

• Beck Depression Inventory (BDI)

• Suicide Behaviors Questionnaire (SBQ-R)

• Screening Tool in Signs of Suicide (SOS)

• Locally developed screening tool

• Other, please specify:_______________________________

5. Where did the screening take place (i.e. in what location or setting was the screening administered)? Select one

• School or school-based health clinic

• College or university

• Mental health (MH) agency (e.g. private MH provider, psychiatric hospital, outpatient clinic)

• Social Service agency (e.g. child welfare, supportive housing)

• Juvenile justice/criminal justice agency (e.g. pretrial services, mental health court)

• Physical health agency (e.g. primary care, pediatrician, emergency department, hospital)

• Community-based organization, recreation or afterschool activity (e.g. Boys & Girls club, faith-based organization)

• Other, please specify:_________________________________

6. Who was screened? Select one

• All youth in attendance (e.g. all youth coming to a primary care provider’s office)

• Youth meeting particular criteria [COMPLETE 6A]

6a. Please describe the criteria used (e.g. youth with suicide attempt history, youth in high-risk demographic categories: ________________________________________________________________________________

7. Please indicate the unduplicated count of number screened: ____________________________________________

Pertains to the number of youth who took the screening questionnaire.

8. Please indicate the unduplicated count of number screened positive:_____________________________________

Pertains to youth who:

1. Screen positive on the screening questionnaire,

2. Self-identify at any point during the screening process

Note: you should complete an EIRF Individual Form (EIRF-I) for all youths who screen positive. Therefore, the unduplicated count of number screened positive should equal the number of EIRF-I forms you complete.

SECTION 2: YOUTH DEMOGRAPHICS FOR ALL YOUTH SCREENED

9. Gender Please indicate the number of youths screened in the following gender categories. Numbers should sum to the total number of youth screened, since each individual screened should fall under a single gender category.

Male
Female
Transgender, female-to-male
Transgender, male-to-female
Transgender, gender non-conforming
Other
Information on gender is missing

10. Race Please indicate the number of youths screened in the following race categories. Numbers should sum to the total number of youths screened, since each individual screened should fall under one of the below single race or multiple race categories.

    Individuals of a single race	American Indian or Alaska Native
    	Asian
    	Black
    	Native Hawaiian or Other Pacific Islander
    	White
    	Other
    	Information on race is missing
    Individuals of more than one race if youth is of more than two races, please include the youth in the category that most closely describes the youth.	American Indian or Alaska Native and Black
    	American Indian or Alaska Native and White
    	Asian and White
    	Black and Asian
    	Black and White
    	Native Hawaiian or Other Pacific Islander and White
    	Individuals reporting multiple races not included above
    	Information on race is missing

11. Hispanic Ethnicty Please indicate the number of screened youths who are of Hispanic ethnicity, the number of screened youths who are non-Hispanic, and the number of screened youths with missing information on Hispanic ethnicity. Numbers should sum to the total number of youths screened, since each individual screened should fall under a single category.

Hispanic/Latino
Non-Hispanic/Latino
Information on Hispanic ethnicity is missing

State/Tribal EIRF-Screening Form Page 4

12/2015