SBHF Data Abstract SBHF Data Abstraction Campus

OMB No. xxxx-xxxx

Expiration Date:

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 40 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation

Campus Suicide Prevention Programs

Instructions:

Please answer each question below to the best of your ability. For assistance, please contact the data collection liaison.

During the year 1 (baseline) administration, you will submit data separately for five academic years (AYs)—the current/most recent AY and the four previous years. For the purpose of this data collection, an academic year includes fall and spring semesters.

Throughout the survey, you will be asked to report whether the information is based on tracked information or an estimate. Tracked information should be reported if it is being supplied from a comprehensive, campus-wide reporting system

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.

Student Behavioral Health Form (SBHF)

SECTION 1. CAMPUS DEMOGRAPHICS

The following information will be pre prefilled with Integrated Postsecondary Education Data System (IPEDS) data.

Total student body enrollment:

Freshman retention:

Are you reporting on an entire academic year?

• Yes

• No

How are you defining an academic year?

______________________________________________________________________________________________

SECTION 2. BEHAVIORAL HEALTH SERVICES ON CAMPUS

1. If a student is in need of behavioral health services (e.g., mental health and substance use), what resources are available through your campus?

Select all that apply. If you select “None” do not select any other items from the list.

• Behavioral health services or on-campus emergency services

• Spiritual or religious counseling

• Referral to an off-campus provider/emergency department

• Transportation to off-campus provider/emergency department

• Other, please specify: ___________________________________

• None

2. [IF “BEHAVIORAL HEALTH SERVICES OR ON-CAMPUS EMERGENCY SERVICES” IS SELECTED FOR Q1, ASK THE FOLLOWING]

Do you have an electronic health record system or management information system on campus to track behavioral health services (e.g., Titanium)?

• Yes

• No

1. [IF NO TO 2] How is information about behavioral health services tracked? _____________________________________

2. [IF NO TO 2] How is information about crisis services tracked? ________________________________________________

3. [IF “BEHAVIORAL HEALTH SERVICES OR ON-CAMPUS EMERGENCY SERVICES” IS SELECTED FOR Q1, ASK THE FOLLOWING]

During the AY, how many students received behavioral health services (e.g., health or substance use) from the counseling center or other campus location?

Total number of students (unduplicated) _______

 Tracked  Estimate

• Information not available

SECTION 3. SCREENINGS AND ASSESSMENT OF RISK

4. Are students being screened/assessed for risk of suicide on campus (e.g., asking students about suicide or depression)?

 Yes  No  Unknown

1. How many students were screened over the course of the AY? ______ (unduplicated)

 Tracked  Estimate  Information not available

2. [IF YES TO 4] Are you implementing universal screenings or are there specific criteria for screening the following? Select all that apply

• All students entering the counseling center

• All students entering the health/wellness center (including physical health)

• All students with an identified behavioral health concern (e.g., referred by faculty)

• All freshmen or first year students

• Other, please specify: _________________________________

3. [IF YES TO 4] Is the screening conducted through informal means (e.g., asking a student if he or she is suicidal) or using a standardized screening tool?

• Formal (e.g., a structured instrument)

• Informal

• Informal and formal

• Unknown

1. [IF “FORMAL” OR “INFORMAL AND FORMAL” ARE SELECTED] What instrument(s) are you using? Select all that apply

• Ask Suicide Screening Questions (asQ)

• Behavioral Health Screen (BHS)

• Columbia Suicide Severity Rating Scale (CSSR-S)

• Counseling Center Assessment of Psychological Symptoms (CCAPS)

• Patient Health Questionnaire (PHQ-9)

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

• Suicide Behaviors Questionnaire (SBQ-R)

• Other, please specify: _______________________________________

4. [IF YES TO 4] During AYXX how many students were identified as at risk of suicide according to your local procedures for identifying risk?

Total number of students who scored positive: ______

 Tracked  Estimate

• Information not available

[IF 4 IS “NO” OR “UNKNOWN”, PROCEED TO Q14]

SECTION 4. SERVICES FOR STUDENTS AT RISK FOR SUICIDE (IDENTIFIED THROUGH SCREENING)

5. Of the students who were identified through screening as at risk for suicide during AYXX (those identified in 4d), how many students received behavioral health (e.g., mental health and substance use) or crisis services on campus? (Unduplicated count of students): _____

 Tracked  Estimate

• Information not available [PROCEED TO QUESTION 7]

• None, students are referred off-campus [PROCEED TO QUESTION 9]

6. [SKIP IF ANSWER TO Q5 IS “NONE”] Of the students identified as at risk for suicide and receiving on campus behavioral health services, how many students are referred from the following sources?

   1. Self-referral _______  Tracked  Estimate

   2. Peer/student or resident advisor (RA) _______  Tracked  Estimate

   3. Campus health services ________  Tracked  Estimate

   4. Other faculty/ staff _______  Tracked  Estimate

   5. Parent or family member ________  Tracked  Estimate

   6. Other _______  Tracked  Estimate

• Information not available

7. [SKIP IF ANSWER TO Q5 IS “NONE”] Of the students at risk for suicide who received behavioral health services on campus (in Q5), how many students received each of the following services on campus? Enter zero if this service is not conducted on campus. If this service is offered, but the number is not available, select “We offer, but number not available”

   1. Behavioral health counseling (e.g., mental health or substance use): _______  Tracked  Estimate

 We offer, but number not available

2. Medication management/psychiatric services ______  Tracked  Estimate

 We offer, but number not available

3. Crisis/emergency services (e.g., transportation to the emergency department)  Tracked  Estimate

 We offer, but number not available

4. Initiation of an on-campus emergency protocol (e.g., lethal means restrictions):_____  Tracked  Estimate

 We offer, but number not available

8. [SKIP IF ANSWER TO Q5 IS “NONE”] Are suicide-specific services (a service that directly addresses suicidality rather than just underlying conditions such as depression) offered on campus? If services are not tracked, but suicide-specific services are provided, select Yes to 8 and “Information not available” for 8a.

• Yes  No

• Unknown

1. [IF YES TO Q8] How many students identified in question 5 received suicide-specific services? (Unduplicated count of students, not services): _____

•  Tracked  Estimate  Information not available

9. How many students identified through screening as at risk for suicide were referred to an off-campus provider for behavioral health or crisis services? (unduplicated count) ______

• We refer students, but the number is not available

• None, we don’t refer students to off-campus facilities

10. [IF Q9 >0 OR “WE REFER STUDENTS, BUT THE NUMBER IS NOT AVAILABLE”] Do you follow up with students after they have been referred to an off-campus facility?

• Yes, at least some

• No

• Unknown

11. [IF YES TO Q10] Approximately what percentage of referrals made have been followed up? ____

 Tracked  Estimate

• Information not available

11a. [IF Q11 IS LESS THAN 100%] If not all referrals are followed-up, what are some of the common barriers preventing follow-up? Select all that apply.

• No staff availability to follow-up

• Student is no longer enrolled at the institution

• No contact information availability

• Staff was unable to reach the student/ the student never responded

• Other, please specify: _______________

12. Of students who were identified as at risk of suicide (through screenings), what is your approach or set of procedures for determining whether or not someone poses high or imminent risk of suicide?

Select either Always, Sometimes, Never for the list of procedures below.

	Always	Sometimes	Never	Don’t Know
Implement level of risk assessment tool (separate from previously mentioned screening instruments)
Assess suicide thoughts, plans, and intent
Assess history of suicide attempts
Assess family history
Assess nonsuicidal self-injury
Assess presence of serious mental illness
Assess availability of means for attempting suicide
Assess presence of depression and/or hopelessness
Assess presence of substance abuse
Ask student to articulate or list reasons for living
Ascertain if the student can agree to a safety contract
Try to develop safety plan with student
Meet with student’s parents or guardians to address concerns and safety issues
Immediately refer the student to speak to a clinician
Other procedure for determining someone who poses high or imminent risk of suicide, please specify: ___________________________________

13. Using your local risk assessment processes described in Q12, for students who are identified at high or imminent risk, what are your typical procedures for managing these students? Do you typically engage in any of the following practices?

Select either Always, Sometimes, Never for the list of procedures below.

	Always	Sometimes	Never	Don’t Know
Call or meet with parents or guardians to discuss monitoring
Call or meet with parents or guardians to provide education about the need for follow-up treatment
Assess safety in the home or residential facility and discuss safety with relevant parties(e.g., removing means of suicide such as firearms)
Discuss alternative ways of coping with distress, or alternatives to suicide with the student
Discuss reasons for living with the student
Work with student to identify individuals the student can contact if feeling suicidal
Refer student to off-campus emergency department or provider
Provide an after-hours emergency contact number to student
If a new referral is given, follow up with the suicidal student and family to see if they followed through with treatment recommendation or need assistance with this
Follow up with the student at school to assess ongoing status/risk
Provide student with national suicide hotline or other crisis hotline phone information
Notify the dean or other faculty
Contact the student’s RA
Administrative case review to discuss at-risk student (eg. BIT Team)
Student is removed from campus for an extended period of time
Student must be monitored by RA or other campus staff
Student is required to attend regular counseling sessions
Other, please specify:

14. Do you provide any postvention services on campus (following a suicide attempt or completion)?

• Always

• Sometimes

• Never

• Unknown

1. [IF ALWAYS OR SOMETIMES TO Q13] What postvention services are available on campus? Select all that apply.

• Community/campus support services

• Group or individual support services

• Peer support groups

• Family support services

• Other: ________________________

SECTION 5. SUICIDE ATTEMPTS AND COMPLETIONS

15. During the AY, how many suicide attempts occurred among students who lived on or off campus?

Total

Gender  Tracked  Estimate

Male: ___

Female: ____

Transgender: _____

Gender unknown or not tracked: ____

Age  Tracked  Estimate

16–20: ____

21–24: ____

>24: ____

Age unknown or not tracked: ____

• Information on number of suicide attempts is not available

1. What source of information did you use to answer these questions?

Select all that apply.

• Electronic health record system

• Grant staff tracking (e.g., Excel spreadsheet)

• On-campus police

• Community police

• Local hospital

• Emergency medical technician (EMT) or other first responder

• Dean’s office

• Academic department (e.g., social work or psychology staff)

• Residential life staff

• Campus-wide incident reporting protocol

• Newspaper or social media

• Other, please specify: ________________________

2. What are your formal campus policies or protocols for a student who has attempted suicide?

Select all that apply.

	Always	Sometimes	Never
Student is removed from campus for an extended period of time
Student must be monitored by RA or other campus staff
Student is required to attend regular counseling sessions
Administrative case review to discuss student
Student is referred to counseling services
No policy
Other, please specify:_________________________

16. During the AY, how many suicide completions occurred among students who lived on or off campus?

Total

Gender  Tracked  Estimate

Male: ___

Female: ____

Transgender: _____

Gender unknown or not tracked: ____

Age  Tracked  Estimate

16–20: ____

21–24: ____

>24: ____

Age unknown or not tracked: ____

• Information on number of suicide completions not available

1. What source of information did you use to answer these questions? Select all that apply.

• Electronic health record system

• Grant staff tracking (e.g., Excel spreadsheet)

• On-campus police

• Community police

• Local hospital

• EMT or other first responder

• Dean’s office

• Academic department (e.g., social work or psychology staff)

• Residential life staff

• Campus-wide incident reporting protocol

• Newspaper or social media

• Vital statistics

• Obituaries

• Other, please specify: ________________________

Campus Student Behavioral Health Form (SBHF) Page 1

12/2015