Justification

OMB No. 0930-0197

Exp. Date 01/13/2011

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 0930-0197.  Public reporting burden for this collection of information is estimated to average .25 hours per client 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 7-1044, Rockville, Maryland, 20857.

User Feedback Survey

Promoting Mental Health and Preventing Suicide:

A Toolkit for Senior Living Communities

1. Type of organization/setting in which the Toolkit was used:

Nursing homes

Assisted living

Independent living

Continuing care retirement community

Other, please describe: ____________________________________

2. Target population served:

a. Gender of adults served is approximately:

____% Female

____% Male

____% Transgender

____% Other (please describe:_____________________________)

b. Adults served range in age from: ______ years (youngest) to _____ years (oldest)

c. Ethnicity of adults served is approximately:

____% Hispanic or Latino

____% Not Hispanic or Not Latino

d. Race of adults served is approximately:

____% American Indian or Alaska Native

____% Asian

____% Black or African American

____% Native Hawaiian or other Pacific Islander

____% White

3. Respondent’s position in organization:

Executive Director

Clinical Director

Activities Director

Dietary Director

Residential Manager

Physician (medical services)

Psychiatrist

Psychologist

Nurse

Social Worker or Counselor

Occupational or Physical Therapist

Other, please describe: ____________________________________

4. How did you become aware of the Toolkit? (please check all sources)

Email

Professional Association listserve or newsletter

SAMHSA news release

SAMHSA website

Conference, meeting, or other event

Colleague

Friend

Other, please describe: ____________________________________

5.a. Have you used the materials from the Getting Started section of the Toolkit (This section contains Basic information to motivate staff, especially in key management positions, to become involved in suicide prevention efforts)?

Yes

No

Can’t recall

5.b. If yes, please check the forums at which the Getting Started information was provided:

Orientation

Executive staff meeting

Clinical staff meeting

All staff meeting

Other, __________________________

5. c. Please check the extent to which the following specific sets of Toolkit materials have been used in your setting.

Key elements of a comprehensive approach to suicide prevention: A guide containing information about tools, programs, activities and policies that are part of a comprehensive approach to reducing the risk of suicide and improving the overall well-being of residents. The guide also contains a self-assessment checklist and planning worksheets to help staff plan and implement new programs, activities, and policies.	Have not used Use occasionally Use frequently	If you have NOT used, please check the reason Lack of time Not relevant Still planning how to use Other, ______________ Other, ______________
Training manual: An instructor’s manual for a series of three one-hour in-service workshops: an overview for all staff; a follow up for nurses’ aides; and a follow up for nurses and social workers.	Have not used Use occasionally Use frequently	If you have NOT used, please check the reason Lack of time Not relevant Still planning how to use Other, ______________ Other, ______________
Resources and tools: A compilation of evidence-based resources and other ideas that staff can use in developing a plan and training staff.	Have not used Use occasionally Use frequently	If you have NOT used, please check the reason Lack of time Not relevant Still planning how to use Other, ______________ Other, ______________
e. Information for residents, families, and other caregivers: Basic information to help residents and caregivers benefit from and participate in the suicide prevention efforts. This section contains fact sheets and a facilitator’s guide for a workshop for residents and caregivers.	Have not used Use occasionally Use frequently	If you have NOT used, please check the reason Lack of time Not relevant Still planning how to use Other, ______________ Other, ______________

6. Overall impressions of the format, organization, and content of the Toolkit. Please check the box that best describes your opinion about each statement.

Overall Impressions	Strongly disagree	Disagree a little	Neither agree or disagree	Agree a little	Strongly agree
In general, information presented within the Toolkit is easy to understand.
The purpose of the Toolkit is clearly stated in the text.
The length of the materials presented in the Toolkit is about right, given the amount of material presented.
The content of the Toolkit is relevant to me and my organization’s needs.
The information provided in the Toolkit is appropriate for the range of staff working in the facility.
The different sets of materials in the Toolkit are organized in a logical order that makes sense to the user.
In general, I understood the language used in the text of the Toolkit.
The current format of the Toolkit helps to organize information clearly for users.
The style and size of the font/type used in the Toolkit are easy to read.

7. If you are using the Toolkit in your setting, to what extent is the Toolkit providing:

	Not at all	A little	Some what	A lot
Motivation for your staff to enhance suicide prevention efforts?
Guidance in implementing activities and policies likely to be effective in reducing suicide in your facility?
Training that increases staff knowledge about suicide and what steps to take to reduce risk among your residents?
Description of, and links to, various resources to help in your suicide prevention efforts?
Useful information for residents and their families and caregivers?

8. Overall, how do you rate the quality of the Toolkit?

Poor

Fair

Good

Very Good

Excellent

Please give reasons for your rating below:

9. Does your organization need additional information or technical assistance in using the Toolkit?

Yes

No

If Yes, please describe your organization’s needs for more information or technical assistance

10. Please provide any additional comments in the space below that you think would assist in improving the Toolkit and its potential usefulness for the field.

Thank you very much for taking the time to complete this survey. Your feedback will assist us in developing materials and resources that will meet your needs and those of the older adults you serve. If you have any questions please contact:

Dr. Jeanne Rivard at (703) 682-9468 or at [email protected]

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