Client Contact Dis Client Contact Disposition Form (All Participants)

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-XXXX. Public reporting burden for this collection of information is estimated to average 9 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, 5600 Fishers Lane, Room 15E45,Rockville, Maryland, 20857. 

988 Suicide & Crisis Lifeline and Crisis Services Program Evaluation

Client Contact Disposition Form

Instructions: Thank you for your help connecting your clients and contacts with this opportunity to share their experiences with the crisis continuum! Please read the script below, in bold, to each person that is eligible to enroll in the survey at the end of your contact with them, after you consider the crisis intervention to be complete.

If the individual is interested in learning more about the study, please complete the questions below. If they prefer not to participate, that’s okay. You do not need to complete this form for those individuals.  Before you begin, here are a few reminders:

Eligibility: All clients ages 13 and older who engage in crisis services on their own behalf are eligible to participate in the survey and interview portions of the study. Third party clients, who contact you out of concern for someone else in crisis, are eligible to participate in the interview portion only.

Survey Participation: Clients will receive an emailed survey invitation from (project specific email address) within 7 days. Please let the client know that they may need to check the spam folder of their email if they don’t receive this message. They may also receive a reminder through phone call or text message if they do not respond to the survey within 2 weeks of the initial invitation.

Interview Participation: Those selected to participate will receive an email, phone call, or text message. Due to limited resources, there may be some cases where we do not contact those who are interested to schedule an interview. For example, this could happen if a lot of people want to participate. We will only contact those that are selected to participate.   

 

Thank you again for your help! 

 

Recruitment Script: 

 

"Before we finish today, I’d like to invite you to take part in a study about the 988 Suicide & Crisis Lifeline and crisis services. This study will help us understand how to support people like you during critical times. By sharing your thoughts on our conversation today and other, similar services you’ve received, you’ll help us improve our services. This study is being conducted by the Substance Abuse and Mental Health Administration (SAMHSA) and their partners.

The study has two parts: online surveys and a telephone or virtual interview. You can participate in either or both. If you choose the surveys, you’ll receive an email with a link to complete them, starting in about a week. You will also receive follow-up surveys about 3 months, 6 months, and 12 months after you finish the first one. Each survey takes about 45 minutes, and you’ll get a $20 gift card for each completed survey. You will get up to $80 if you do all four. If you're interested, you may also be invited to complete an interview, which lasts about an hour and can be done over the phone or via video call. If selected, you’ll receive a $50 gift card. Keep in mind that not everyone contacted for the interview will participate. When the study team contacts you, they’ll provide more details, and you can decide whether to participate.

Does this sound like something you would be interested in?

[If yes] Great, thank you for your help! We’re really excited to learn more with your help. Are you interested in participating in the surveys, the interview, or both? I just have a couple more questions for you about the best way to send you the survey. [Continue with CCDF form as appropriate].

[If no] That’s okay. Thanks for spending a few minutes with me while I talked through that [Continue with typical contact closure procedures].”

   

Item Number	Question	Response Options
N/A	CCDF ID	Automatically Generated Sequential ID
N/A	Submitting Crisis Agency Name	Pre-Populated User Account Data
N/A	Submitting Crisis Agency Type	Pre-Populated User Account Data
N/A	Submitting Crisis Agency State	Pre-Populated User Account Data
N/A	Submitting Crisis Agency Zip Code	Pre-Populated User Account Data
N/A	Submitting Crisis Agency Grant Program (if grantee)	Pre-Populated User Account Data
N/A	Submitting Crisis Counselor/Staff Name	Pre-Populated User Account Data
N/A	Submitting Crisis Counselor/Staff Work Email Address	Pre-Populated User Account Data
N/A	Submitting Crisis Counselor/Staff Work Phone Number	Pre-Populated User Account Data
N/A	Date and time when the form was started	Automatically Logged Date/Time
N/A	Date and time when the form was submitted	Automatically Logged Date/Time
	SECTION 1. Contact Status. Before beginning this form, please indicate whether you are completing this form with a client who engaged with crisis services on their own behalf, or a third-party client, who contacted you out of concern for someone else in crisis. If this contact involved both parties, and both are interested in study participation, please complete this form for each individual separately.	----
1.	Are you completing this form with an individual who engaged with crisis services on their own behalf, or a third-party client who contacted you out of concern for someone else in crisis?	1=Individual Crisis Contact  2=Third-Party Crisis Contact 3=Other, please specify: [Open ended response]
----	SECTION 2. Consent to Contact. Please read each of the questions below directly to the individual interested in enrolling in this study and record their responses. If you have already collected contact information from this individual for another purpose, please go through each question and confirm whether it is okay to share each piece of information for the purposes of survey and/or interview recruitment (e.g., “Earlier, you told me that your email address was email@address.com. Is it okay if the research and evaluation team uses this email address to contact you?”). Contact information should only be recorded on this form if the participant wishes to share it with the research and evaluation team.	----
2.	Is it okay if our study partners contact you about participating in the surveys?	0=No  1=Yes
3.	Is it okay if our study partners contact you about participating in the telephone interview?     Programmer:  Display Q3 only to those who select option 1 (Individual Crisis Contact) on Q1 Skip to end of form if ‘No’ is selected for Q2 AND Q3 for Individual Crisis Contacts OR if ‘No’ is selected for Q2 for Third-Party Crisis Contacts	0=No  1=Yes
4.	What is your age?	1= 12 or Younger [Go to end of form] 2= 13 to 17 years old [Continue to Q4a] 3=18 to 25 years old [Go to Q5] 4=26-29 years old  [Go to Q5] 5=30-39 years old  [Go to Q5] 6=40-49 years old  [Go to Q5] 7=50-59 years old  [Go to Q5] 8=60-65 years old  [Go to Q5] 9=66-74 years old  [Go to Q5] 10=75-84 years old  [Go to Q5] 11=85 and older  [Go to Q5]
4a.	We need permission from your parent or caregiver before you can complete the surveys. We will send them a link to complete this form via email. What is the best email address for your parent or caregiver?     This information will only be used to share information about this survey opportunity and ask them if it’s okay for you to participate. The research and evaluation team will not know about or share anything else that we talked about today. If they agree that it’s okay for you to participate, we’ll reach out to you directly after that.	Open text (alphanumeric)  77=Not Applicable  88=Client Prefers Not to Respond  99=Don’t Know
4b.	If we’re not able to reach them through email, we may also try to reach them through text message or phone call. Does your parent or guardian have a phone number that we could use to reach them if needed?	0=No [Go to Q5] 1=Yes [Continue to Q4 88=Client Prefers Not to Respond  [Go to Q5] 99=Don’t Know  [Go to Q5]
4c.	What is the best phone number to reach your parent or caregiver?	Open Text (numeric)  [Go to 4d.] 77=Not Applicable  88=Client Prefers Not to Respond  99=Don’t Know
4d.	May we use this number to reach your parent or caregiver by phone, text, or both?	1=Phone Call Only  2=Text Message Only  3=Both Phone Call and Text Message  77=Not Applicable  88=Client Prefers Not to Respond  99=Don’t Know
4e.	What is your name, so that the study team knows what to call you?	Open Text (alphanumeric)  88=Client Prefers Not to Respond
5.	What is your name, so that the study team knows what to call you?	Open Text (alphanumeric)  88=Client Prefers Not to Respond
6.	What is your preferred e-mail address? If you said you were interested in survey participation earlier, you will receive an invitation to participate in your first survey via email within one (1) week of completing this form.	Open Text (alphanumeric)  [Continue to Q8] 88=Client Prefers Not to Respond  [Go to Q9] 99=Don’t Know  [Go to Q9]
7.	Do you have a secondary e-mail address that we could use to reach you in case you don’t receive our first emails to your primary email?	0=No  [Go to Q9] 1=Yes  [Continue to Q8a] 88=Client Prefers Not to Respond  [Go to Q9] 99=Don’t Know [Go to Q9]
8.	What is a secondary e-mail address that we could use to reach you?	Open Text (alphanumeric)  77=Not Applicable  88=Client Prefers Not to Respond  99=Don’t Know
8a.	We will reach out to you via email first. Do you have a phone number that we could use to reach out to you through phone call or text message if needed?	0=No  [Go to Section 3] 1=Yes  [Continue to Q9a] 88=Client Prefers Not to Respond [Go to Section 3]   99=Don’t Know  [Go to Section 3]
9.	What phone number can we use to contact you?	Open Text (numeric)  77=Not Applicable  88=Client Prefers Not to Respond  99=Don’t Know
9a.	May we use this number to reach you by phone, text, or both?	1=Phone Call Only  [Continue to Q9c] 2=Text Message Only  [Go to Q10] 3=Both Phone Call and Text Message  [Continue to Q9c] 77=Not Applicable  [Go to Q10] 88=Client Prefers Not to Respond [Go to Q10]   99=Don’t Know [Go to Q10]
9b.	May we leave a voicemail message for you at this number? Our message will include only general references to ‘a study about healthcare services that you recently expressed interest in’ and will not include details about your crisis services.	0=No  1=Yes  88=Client Prefers Not to Respond
9c.	Do you have a secondary phone number that we could use to reach you if needed?	0=No  [Go to Q11] 1=Yes  [Continue to Q10a] 88=Client Prefers Not to Respond  [Go to Q11] 99=Don’t Know [Go to Q11]
10.	What is your secondary phone number?	Open Text (numeric) [Continue to Q10b] 77=Not Applicable [Go to Q11]   88=Client Prefers Not to Respond [Go to Q11]   99=Don’t Know [Go to Q11]
10a.	May we use this number to reach you by phone, text, or both?	1=Phone Call Only [Continue to 10c] 2=Text Message Only [Go to 11] 3=Both Phone Call and Text Message [Continue to 10c] 77=Not Applicable [Go to 11] 88=Client Prefers Not to Respond [Go to 11]   99=Don’t Know [Go to 11]
10b.	May we leave a voicemail message for you at this number? Our message will include only general references to ‘a study about healthcare services that you recently expressed interest in’ and will not include details about your crisis services.	0=No  1=Yes  77=Not Applicable  88=Client Prefers Not to Respond
10c.	If we need to reach you through phone call or text message, what is the best day for us to reach out? Select all that apply	1=Mondays [Continue to Q12] 2=Tuesdays [Continue to Q12] 3=Wednesdays [Continue to Q12] 4=Thursdays [Continue to Q12] 5=Fridays [Continue to Q12] 6=Saturdays [Continue to Q12] 7=Sundays [Continue to Q12] 8=Please only contact me by email [Go to Section 3] 77=Not Applicable [Go to Section 3] 88=Client Prefers Not to Respond [Go to Section 3]  99=Don’t Know [Go to Section 3]
11.	What time zone are you in? This should be the same time zone you had in mind when you answered the previous question.	1=Eastern Time   2=Central Time  3=Mountain Time  4=Pacific Time  5=Other, please specify: [Open ended response] 77=Not Applicable  88=Client Prefers Not to Respond  99=Don’t Know
12.	What is the best time for us to reach you on these days? As you respond to this question, please consider your local time zone.	1= Mornings (8 am – 11 am)  2= Afternoons (12 pm – 4 pm)  3=Evenings (5 pm – 8pm)  4=It depends on the day. Please specify the best times to reach you here: [Open ended response] 77=Not Applicable 88=Client Prefers Not to Respond  99=Don’t Know
13.	Thank you for completing this section of the form! If eligible, the potential participant will receive an email or call from the study team soon. Please thank the participant for the time they spent answering questions.	----
----	SECTION 3. Crisis Service Characteristics. Please respond to the questions below based on the crisis contact/conversation that directly led to their recruitment into this study. This section should be completed by the crisis service provider after the contact is completed. These questions should not be completed by individuals interested in enrolling in this study.	----
----	Was this interaction or individual assigned an ID number by your contact center/agency?	0=No  [Go to Q15] 1=Yes  [Continue to Q14a] 99=Don’t Know  [Go to Q15]
14.	Please enter the assigned interaction or individual ID number here.	Open Text (alphanumeric)  77=Not Applicable  99=Don’t Know
14a.	Was this interaction routed through any of the following sub-networks? Select all that apply. Programmer: Display question only if agency type is crisis contact center.	1= Veteran’s Crisis Line 2= Spanish 3= TrevorLifeline, TrevorChat, or TrevorText 4= ASL Videophone, TTY, or Relay Device 5=National Backup
15.	What was the primary language used during this contact?	1=English  [Go to 16] 2=Spanish [Continue to Q15a] 3=American Sign Language 4=Other, please specify: [Open ended response] [Continue to Q15a] 77=Not Applicable [Go to 16] 99=Don’t Know [Go to 16]
16.	Was a translator used to conduct this contact?	0=No  1=Yes  99=Don’t Know
16a.	Who did you primarily speak with during this contact?	1=Individual in Crisis  2=Third Party  3=Other, please specify: [Open ended response] 77=Not Applicable  99=Don’t Know
17.	What modality was used for this crisis contact?	1= Phone Call  2=Text Message  3=Chat  4=In-person/face-to-face  99=Don’t Know
18.	What was this individual’s primary, or most discussed, concern during the conversation today?	1=Abuse/Adult  2=Abuse/Child  3=Abuse/Elder  4=Anxiety  5=Basic needs  6=Bullying  7=Career choices  8=COVID 19  9=Depression  10=Eating Disorders  11=Family  12=Financial problems  13=Friends, Peers, Neighbors  14=Grief  15=HIV or AIDS  16=Job loss  17=Legal issues  18=Loneliness  19=Major Current Event  20=Marital or Partner  21=Medication Issues  22=Military Experience  23=Natural or Manmade Disaster  24=Physical Disability  25=Physical Health  26=Pregnancy  27=Recent psychiatric hospitalization  28=Requesting information  29=Self Harm  30=Sexual Assault  31=Sexual Health  32=Substance Use/Addiction  33=Suicide  34=Workplace concerns  35=Other, please specify: [Open ended response] 77=Not Applicable  88=Client Did not Disclose  99=Don’t Know
19.	What was this individual’s secondary, or second most discussed, concern during the conversation today?	1=Abuse/Adult  2=Abuse/Child  3=Abuse/Elder  4=Anxiety  5=Basic needs  6=Bullying  7=Career choices  8=COVID 19  9=Depression  10=Eating Disorders  11=Family  12=Financial problems  13=Friends, Peers, Neighbors  14=Grief  15=HIV or AIDS  16=Job loss  17=Legal issues  18=Loneliness  19=Major Current Event  20=Marital or Partner  21=Medication Issues  22=Military Experience  23=Natural or Manmade Disaster  24=Physical Disability  25=Physical Health  26=Pregnancy  27=Recent psychiatric hospitalization  28=Requesting information  29=Self Harm  30=Sexual Assault  31=Sexual Health  32=Substance Use/Addiction  33=Suicide  34=Workplace concerns  35=Other, please specify: [Open ended response] 77=No Secondary Concern/Not Applicable  88= Client Did not Disclose  99=Don’t Know
20.	Did this individual present with suicidal ideation/suicide risk (or did the third-party express concern for someone at risk of suicide)?	0=No  1=Yes  99=Don’t Know
21.	Was a suicide risk assessment completed during this conversation?	0=No  [Go to Q22] 1=Yes  [Continue to Q21a] 99=Don’t Know  [Go to Q22]
22.	Was the individual at-risk determined to be at low, moderate, or high risk of suicide?	1=Low  2=Moderate  3=High  4=Other, please specify: [Open ended response] 77=Not Applicable  99=Don’t Know
22a.	Was the individual determined to be at imminent risk for suicide?	0=No  1=Yes  77=Not Applicable  99=Don’t Know
22b.	Did this individual present with homicidal ideation or risk of violence towards others (or did the third-party express concern for someone at risk of homicide/violence toward others)?	0=No  1=Yes  99=Don’t Know
23.	Did this individual present with a substance use crisis/risk of overdose (or did the third-party express concern for someone with a substance use crisis/at risk of overdose)?	0=No  1=Yes  99=Don’t Know
24.	What was the result of this contact?	1= Resolved without need for additional intervention   [Go to Q25] 2=Resulted in Emergency Rescue – Voluntary  [Continue to Q24a] 3=Resulted in Emergency Rescue – Involuntary  [Continue to Q24a] 4=Resulted in Mobile Crisis Outreach Referral  [Go to Q25] 5=Other, please specify: [Open ended response] [Go to Q25] 77=Not Applicable  [Go to Q25] 99=Don’t Know  [Go to Q25]
25.	Was law enforcement dispatched to assist this individual during this contact?	0=No  1=Yes  99=Don’t Know
25a.	Did this contact involve a suicide attempt, attempted violence toward others, or overdose in progress? Select all that apply.	0=No  1=Yes, Suicide Attempt  2=Yes, Overdose in Progress  3=Yes, Violence Towards Others in Progress  99=Don’t Know
26.	Did you make a referral for this individual based on this contact?	0=No  [Go to Q27] 1=Yes  [Continue to Q26a] 77=Not Applicable  [Go to Q27] 99=Don’t Know  [Go to Q27]
27.	How many total referrals did you make for this individual?	Open Text (numeric)  99=Don’t Know
27a.	What type of service was this individual referred to? Select all that apply.	1=Public mental health agency or provider 2=Private mental health agency or provider   3=Psychiatric hospital/unit   4=Emergency department   5=Substance use treatment provider   6=School or university counselor 7=Mobile Crisis Unit   8=Crisis Follow-Up Program  9=Tribal services   10=Non-hospital crisis stabilization unit  11=School or academic organization 12=Community based organization, recreation, religious, or afterschool program 13=Physical health provider 14=Law enforcement/Juvenile justice agency 15=Social service agency 16=Other, please specify: [Open ended response] 77=Not Applicable  99=Don’t Know
27b.	Did this individual receive a referral to or services from a designated Certified Community Behavioral Health Clinic (CCBHC) as part of their contact with you today?	0=No  1=Yes  99=Don’t Know
28.	Will this individual receive a follow-up contact from you or your agency related to today’s intervention?	0=No  [Go to end of form] 1=Yes  [Continue to 28a] 99=Don’t Know  [Go to end of form]
29.	How many follow-up contacts do you or your agency plan to make with this individual?	Open Text (numeric)  77=Not Applicable  99=Don’t Know
29a.	Over what period of time do you or your agency plan to follow-up with this individual?  Please indicate the total time period over which all planned follow-up contacts will occur.	1=24 Hours  2=48 Hours  3= 72 Hours   4= More than 72 Hours but Less Than One Week  5=One Week  6=Two Weeks  7=Three Weeks  8=Four Weeks  9=Longer Than Five Weeks, please specify: [Open ended response]   77=Not Applicable  99=Don’t Know
29b.	Thank you for completing Section 3 of this form! We appreciate your time and your contribution to this study.	----
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