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OMB No. 0930-0286
Expiration Date: 05/31/10
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 .75 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.
Cross-site Evaluation of the
Garrett Lee Smith Memorial (GLS) Campus Suicide Prevention Program
Prevention Strategies Inventory
(Campus Version)
Instructions for the respondent: Thank you for taking the time to complete this
inventory. The Prevention Strategies Inventory (PSI) is designed to catalogue: (1) the
prevention strategies being developed and implemented and (2) the percent of GLS funds
expended to date by prevention strategy category. Some of the activities, products and
services that you are implementing locally are pre-established in the field of suicide
prevention and others are products and services that you are developing for local use –
this inventory will catalogue information about both. This administration of the
inventory will ask you to think back over the first two quarters of your grant funding;
subsequent administrations will be quarterly and will ask that you provide information
about the preceding quarter.
Before beginning the online inventory, please read carefully the following consent form
and click the “I CONSENT” button at the end to indicate that you agree to participate in
this data collection effort. It is very important that you understand that your participation
in this inventory is voluntary and that the information you share is private. This inventory
will take approximately 45 minutes.
As part of the cross-site evaluation of the Garrett Lee Smith (GLS) Memorial Suicide
Prevention Program through funding from SAMHSA, we are asking that you complete
this inventory of prevention strategies. The Prevention Strategies Inventory (PSI) is
designed to catalogue on a quarterly basis: (1) the prevention strategies being developed
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and implemented and (2) the percent of GLS funds expended to date by prevention
strategy category. Your consent requires that you read and agree to the following:
Privacy: The information that you provide via this online inventory will be kept private
except as otherwise required by law. No identifying information is requested as part of
the inventory. The information that we report to SAMHSA will not contain any
identifying information and your name will not be used in any reports about this
evaluation.
Risks: Completion of this inventory poses few, if any, risks to you. You may choose to
cease input of information at any time or not answer a question, for whatever reason.
Your participation is voluntary. Refusal to participate involves no penalty or adverse
consequences. If you consent to complete the inventory here are some additional things
you should know:
•
•
•
•
•
You may stop your input of data at any time without penalty or consequence.
You may chose to not answer a question at any time without penalty or
consequence.
You may contact the cross-site evaluation Project Director or Database
Administrator with any questions that you have about the evaluation and/or
the Prevention Strategies Inventory before, during or after you have
completed the inventory.
We encourage you to print a copy of this consent for your records.
Again, your name will not be used in any reports about this inventory.
Contact information: If you have any concerns about your participation in this study or
have any questions about the evaluation, please contact Christine Walrath, Principal
Investigator at [email protected] or at 212-9415555. Please click the “I CONSENT” box below to proceed to the Prevention Strategies
Inventory.
“I CONSENT” (Move to next web page to start the inventory)
“I DO NOT CONSENT” (Move to the web page which should say “Thank
you for considering participation in collection of data through the
Prevention Strategies Inventory. Please contact Christine Walrath,
Principal
Investigator
at
[email protected] or at 212-941-5555 with any questions.”
and offer them an opportunity to go to the inventory’s Homepage.
Thank you!
The Prevention Strategies Inventory is organized as follows.
Part A: Suicide Prevention Program Strategies: This section will ask you to select
the prevention strategies that are being developed and implemented in your
suicide prevention program.
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Part B: Follow Up Questions on Selected Strategies: For each of the prevention
strategies you selected in Part 1, you will be asked follow up questions.
Part C: Budget: This section will ask for the amount of the total GLS budget
expended to date and the percent of funds expended to date by prevention strategy
category.
If at any time while you are working to complete this inventory you need to save your
entry and come back to it at a later time (before submitting as final), you can do so by
clicking the “NEXT PAGE” button in order to save your responses. You can then close
the survey webpage.
If you have questions or need help related to entering information, please send an email
to [email protected] for assistance. To begin the inventory, enter
your login name and password below. If you do not remember your login name and/or
password please refer to the email sent to you by ICF Macro about completing the
Prevention Strategies Inventory.
Login Name: _______________________
Password:________________________
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NOTE: BASELINE AND FOLLOW UP VERSIONS ARE IDENTICAL. FOLLOW UP
VERSION WILL BE PRE-POPULATED WITH INFORMATION FROM PREVIOUS
ADMINISTRATION.
SECTIONS:
A.
B.
1.
2.
3.
4.
5.
6.
7.
8.
9.
C.
SUICIDE PREVENTION PROGRAM STRATEGIES
FOLLOW UP QUESTIONS ON SELECTED STRATEGIES
OUTREACH AND AWARENESS
1.1.
Public Awareness Campaigns
1.2.
Outreach and Awareness Activities and Events
1.3.
Outreach and Awareness Products
GATEKEEPER TRAINING
ASSESSMENT, REFERRAL, AND CLINICAL TRAINING FOR MENTAL
HEALTH PROFESSIONALS AND HOTLINE STAFF
3.1.
Assessment and Clinical Training for Mental Health Professionals
3.2. Assessment and Referral Training for Hotline Staff
LIFESKILLS AND WELLNESS ACTIVITIES
HOTLINES AND HELPLINES
MEANS RESTRICTION
6.1. Public Awareness Campaigns
6.2. Outreach & Awareness Events
6.3. Outreach & Awareness Products
POLICIES AND PROTOCOLS FOR INTERVENTION AND POSTVENTION
7.1. Policies and protocols related to intervention
7.2. Policies and protocols related to postvention
COALITIONS AND PARTNERSHIPS
8.1.
Leading or substantially supporting a Suicide Prevention Coalition
8.2. Participating in coalitions related to youth prevention
8.3.
Partnerships with agencies and organizations
OTHER SUICIDE PREVENTION STRATEGIES
BUDGET
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A.
SUICIDE PREVENTION PROGRAM STRATEGIES
1. What types of suicide prevention strategies are being implemented under your
GLS program? Select all that apply
OUTREACH AND AWARENESS
Public Awareness Campaigns
[A Public Awareness Campaigns is an organized systematic effort through
various communications media to make the general public or particular
target populations aware of key messages in suicide prevention. Examples
of Public Awareness Campaign are: “Be Well to Do Well (BW2DW)”
mental health awareness campaign, “I Am Not a Bystander” campaign,
"How YOU Doin'?" campaign, "Suicide Shouldn't Be A Secret", “Ask,
Listen and Refer” Campaign, "Don't Erase Your Future" campaign etc.,]
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. Examples of these types of activities are: a suicide prevention
poster contest, out of darkness walk, 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. Examples of
these types of 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 and staff identify individuals at risk of suicide and to refer them for
help. Participants in gatekeeper trainings may include students,
parents/guardians, Resident Advisors, student leaders, clerical staff, public
safety or other emergency response staff, university or college
administrators, health and wellness professionals, clergy and faculty
members and the larger community that the campus is part of (such as
local high schools or community-based organizations).]
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ASSESSMENT, CLINICAL, AND REFERRAL TRAINING FOR MENTAL
HEALTH PROFESSIONALS AND HOTLINE STAFF
Assessment and clinical training for mental health professionals
[This category refers to training mental health professionals on assessing
and managing 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
and sexual/dating violence assessment.]
Assessment and referral training for hotline staff
[This category refers to training hotline staff in suicide risk assessment
and referral skills.]
LIFESKILLS AND WELLNESS ACTIVITIES
Life skills and wellness activities
[This category refers to activities (workshops, educational seminars,
speaking events and trainings) that aim to provide students with essential
lifeskills and promote wellness. These activities intend to support
positive social, emotional, spiritual and academic development. They help
to increase connectedness to the campus community. Lifeskills include
depression and stress management, communication, problem-solving,
anger regulation and goal-setting. Examples of these types of activities
are: a workshop to increase students' resilience to stress and negative life
events; a workshop on healthy relationships; a seminar on depression,
anxiety, eating disorders and body image; tai chi; yoga; meditation;
progressive muscle relaxation; and dance and movement.]
HOTLINES AND HELPLINES
Developing, maintaining or supporting crisis hotlines and helplines
[This strategy refers to developing, maintaining or supporting hotline or
helpline services for the campus community. For example, a grantee may
use GLS funds to develop and maintain a hotline service for students or a
grantee uses funds to develop a local call center for the National Suicide
Prevention Hotline. Please note that training for hotline staff should be
indicated under another category “Assessment and Referral Training for
Hotline Staff”. Also, materials promoting the National Suicide Prevention
Lifeline should be reported under “Outreach and Awareness Products”.]
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MEANS RESTRICTION
[This strategy refers to efforts to educate about the issue of lethal means
restriction. Examples of efforts that would be reported under this category would
be a campaign dedicated to reducing access to lethal means, and outreach and
awareness events, activities and materials focused on access to lethal means.]
Public Awareness Campaigns
[A Public Awareness Campaigns 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: “Lock 'Em Up” Prescription Drug Campaign.]
Outreach & Awareness Events
[Outreach and awareness events or activities intended to promote
awareness about access to lethal means and not connected to a particular
public awareness campaign.]
Outreach & Awareness Products
[Outreach and awareness 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.]
POLICIES AND PROTOCOLS FOR INTERVENTION AND
POSTVENTION
[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 support (assessment, referral, treatment and follow-up). 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 campus community following a suicide and to prevent
cluster suicides. 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 formal written statements documenting the procedures to be
followed.]
Policies and protocols related to intervention
Policies and protocols related to postvention
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COALITIONS AND PARTNERSHIPS
[Please indicate whether you are using GLS funds to: lead or substantially support
a suicide prevention coalition; participate in related youth prevention coalitions
such as youth substance abuse coalition; and partner with on-campus
departments/agencies/organizations and off-campus agencies/organizations.]
Leading or substantially supporting a Suicide Prevention Coalition
Participating in coalitions related to youth prevention
Partnerships with agencies and organizations
OTHER SUICIDE PREVENTION STRATEGIES
[Please report any other suicide prevention strategies that are not listed above.]
Other
Please specify: ____________
Other
Please specify: ____________
Other
Please specify: ____________
Other
Please specify: ____________
Subsequent sections will be restricted to the strategies that the respondent selected in Q1.
For each strategy, grantees can report multiple entries. For example, under “Public
Awareness Campaigns”, they can enter information about each campaign separately. Or
under “Policies and protocols related to intervention”, they can enter multiple protocols
separately.
SECTION B FOLLOW UP QUESTIONS ON SELECTED STRATEGIES
1. OUTREACH AND AWARENESS
1.1. Public Awareness Campaigns
1. What is the name of the public awareness campaign?
__________________________________________________________________
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2. Please describe the public awareness campaign – its goals, methods/elements and
intended audiences.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Please indicate the populations targeted by the public awareness campaign.
Student
Parents/guardians
Staff
Clerical/administrative support
Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other__________ (Please specify)
4. 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 & flyers
Please describe:
____________________________________________________________
____________________________________________________________
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Print media such as newspapers/magazines/newsletters
Please describe:
____________________________________________________________
____________________________________________________________
Billboards
Please describe:
____________________________________________________________
____________________________________________________________
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Please describe:
____________________________________________________________
____________________________________________________________
Website development/enhancement
Please describe:
____________________________________________________________
____________________________________________________________
Radio
Please describe:
____________________________________________________________
____________________________________________________________
TV
Please describe:
____________________________________________________________
____________________________________________________________
DVD
Please describe:
____________________________________________________________
____________________________________________________________
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Events/activities
Please describe:
____________________________________________________________
____________________________________________________________
Booth at health fair
Please describe:
____________________________________________________________
____________________________________________________________
Other
Please describe:
____________________________________________________________
____________________________________________________________
5. What methods are you using to evaluate the effectiveness of this public awareness
campaign?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
1.2. Outreach and Awareness Activities and Events
1. What is the name of activity/event?
__________________________________________________________________
2. Type of activity/event
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Booth at health fair
Out of darkness walk
Poster contest
Other events/activities
Please enter type: __________________
3. Please describe the activity or event. Explain how the activity or event relates to
the goals of your suicide prevention program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the populations targeted by the activity or event.
Student
Parents/guardians
Staff
Clerical/administrative support
Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other__________ (Please specify)
6. What methods are you using to evaluate the effectiveness of this activity or event?
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Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
1.3. Outreach and Awareness Products
1. What is the name of product?
__________________________________________________________________
2. Type of product
Print materials such as brochures, posters & flyers
Print media such as newspapers/magazines/newsletters
Billboards
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Website development/enhancement
Radio
TV
DVD
Newspaper/magazine/newsletter
Other product
Please describe: ___________________
3. Please describe the product. Explain how this product relates to the goals of your
suicide prevention program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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4. Please indicate the populations targeted by the product.
Student
Parents/guardians
Staff
Clerical/administrative support
Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other__________ (Please specify)
5. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
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2. GATEKEEPER TRAINING
2.1. Gatekeeper Training
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
Other Please describe: _______________________
Is this a locally developed training?
Yes
No
3. 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 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.
Student
Parents/guardians
Staff
Clerical/administrative support
Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
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Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other__________ (Please specify)
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
3. ASSESSMENT, CLINICAL, AND REFERRAL TRAINING FOR MENTAL
HEALTH PROFESSIONALS AND HOTLINE STAFF
3.1. Assessment, Clinical, and Referral Training for 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)
Other (Please describe): ____________________
Is this a locally developed training?
Yes
No
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3. 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 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): ____________
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
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3.2. Assessment and Referral Training for Hotline Staff
1. What is the name of the training?
__________________________________________________________________
2. Please indicate the type of training:
__________________________________________________________________
3. Please describe the training.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the types of trainees.
Mental health clinician/counselor/ psychologist
Social Worker / Caseworker / Care coordinator
Volunteers
Other (Please specify): ____________
5. What methods are you using to evaluate the effectiveness of this training?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
4. LIFESKILLS AND WELLNESS ACTIVITIES
1. What is the name of the activity?
__________________________________________________________________
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2. Please describe the activity (include its purpose and how it relates to suicide
prevention efforts).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What methods are you using to evaluate the effectiveness of this activity?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
5. HOTLINES AND HELPLINES
1. What is the name of the hotline/helpline?
__________________________________________________________________
2. Please describe the hotline/helpline.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What methods are you using to evaluate the effectiveness of the crisis hotline?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
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Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
6. MEANS RESTRICTION
6.1.
Public Awareness Campaign
1. What is the name of the public awareness campaign?
__________________________________________________________________
2. Please describe the public awareness campaign – its goals, methods/elements and
intended audiences.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. Please indicate the populations targeted by the public awareness campaign.
Student
Parents/guardians
Staff
Clerical/administrative support
Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
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Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other__________ (Please specify)
4. 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 & flyers
Please describe:
____________________________________________________________
____________________________________________________________
Print media such as newspapers/magazines/newsletters
Please describe:
____________________________________________________________
____________________________________________________________
Billboards
Please describe:
____________________________________________________________
____________________________________________________________
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Please describe:
____________________________________________________________
____________________________________________________________
Website development/enhancement
Please describe:
____________________________________________________________
____________________________________________________________
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Radio
Please describe:
____________________________________________________________
____________________________________________________________
TV
Please describe:
____________________________________________________________
____________________________________________________________
DVD
Please describe:
____________________________________________________________
____________________________________________________________
Events/activities
Please describe:
____________________________________________________________
____________________________________________________________
Booth at health fair
Please describe:
____________________________________________________________
____________________________________________________________
Other
Please describe:
____________________________________________________________
____________________________________________________________
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5. What methods are you using to evaluate the effectiveness of this public awareness
campaign?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
6.2. Outreach and Awareness Activities and Events
1. What is the name of activity/event?
__________________________________________________________________
2. Type of activity/event
Booth at health fair
Out of darkness walk
Poster contest
Other events/activities
Please enter type: __________________
3. Please describe the activity or event. Explain how the activity or event relates to
the goals of your suicide prevention program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Please indicate the populations targeted by the activity or event.
Student
Parents/guardians
Staff
Clerical/administrative support
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Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other__________ (Please specify)
7. What methods are you using to evaluate the effectiveness of this activity or event?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
6.3. Outreach and Awareness Products
1. What is the name of product?
__________________________________________________________________
2. Type of product
Print materials such as brochures, posters & flyers
Print media such as newspapers/magazines/newsletters
Billboards
FINAL Product and Services Inventory (Campus)
11.31.2009
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Document A.2
Awareness products (such as stressballs, keychains, mood pens, T-shirts
etc.,)
Website development/enhancement
Radio
TV
DVD
Newspaper/magazine/newsletter
Other product Please describe: ___________________
3. Please describe the product. Explain how this product relates to the goals of your
suicide prevention program.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
1. Please indicate the populations targeted by the product.
Student
Parents/guardians
Staff
Clerical/administrative support
Public safety or other emergency response staff
Residential life
Facilities maintenance
Other staff
University or College Administrator
Health and Wellness Professionals
Mental health/counseling
Primary care (physical health)
Other health professional
Faculty Member or Researcher
Clergy
Community (outside of campus such as local high schools or community-
based organizations)
__________ (Please specify)
__________ (Please specify)
__________ (Please specify)
Other _________ (Please specify)
FINAL Product and Services Inventory (Campus)
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Document A.2
2. What methods are you using to evaluate the effectiveness of this product?
Qualitative Methods
Focus Groups
Qualitative questionnaires
Key Informant Interviews
Other (Please specify): _______________
Quantitative Methods
Surveys
Assessments/Measures
Other (Please specify): _______________
None, there are no plans to evaluate this product/service.
7. POLICIES AND PROTOCOLS FOR INTERVENTION AND POSTVENTION
7.1. Policies and protocols related to intervention
1. What is the name of the policy/protocol?
__________________________________________________________________
2. Please provide a brief description of the policy or protocol (include elements such
as procedures for responding to youth at risk, types of campus
departments/personnel and outside agencies involved in the protocol and their
respective roles and responsibilities, description of how the protocol will be
communicated, reviewed and evaluated etc.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7.2. Policies and protocols related to postvention
1. What is the name of the policy/protocol?
__________________________________________________________________
FINAL Product and Services Inventory (Campus)
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Document A.2
2. Please provide a brief description of the policy or protocol (include elements such
as postvention procedures for responding to completed suicide, types of campus
departments/personnel and outside agencies involved in the protocol and their
respective roles and responsibilities, description of how the protocol will be
communicated, reviewed and evaluated etc.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
8. COALITIONS AND PARTNERSHIPS
8.1. 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 elements such as 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.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8.2. Participating in coalitions related to youth prevention
1. What is the name of the coalition?
__________________________________________________________________
2. Please provide a brief description of the coalition (include elements such as how
does your participation in this coalition advance your suicide prevention efforts,
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.,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
FINAL Product and Services Inventory (Campus)
11.31.2009
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Document A.2
8.3. Partnerships with agencies and organizations
1. Please provide a brief description of your efforts to build partnerships with youthserving agencies and organizations (on campus and off campus partnerships).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
OTHER SUICIDE PREVENTION STRATEGIES
1. Please provide a brief description of this suicide prevention strategy (include
elements such as type of strategy, target populations etc,).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
FINAL Product and Services Inventory (Campus)
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Document A.2
SECTION C BUDGET
1. How much of your GLS budget (including any matching funds) have you spent to
date? Specify dollar amount:
2. Please estimate the percentage of your total budget expended to date on the
following prevention strategies.
OUTREACH AND AWARENESS
¾
¾
¾
Public Awareness Campaigns
Outreach and Awareness Activities and Events
Outreach and Awareness Products
GATEKEEPER TRAINING
___%
___%
___%
___%
___%
ASSESSMENT AND REFERRAL TRAINING FOR MENTAL HEALTH
PROFESSIONALS AND HOTLINE STAFF
___%
¾
¾
Assessment and Referral Training for Mental Health
Professionals
Assessment and Referral Training for Hotline Staff
___%
___%
LIFESKILLS AND WELLNESS ACTIVITIES
___%
SCREENING PROGRAMS AND TOOLS
___%
HOTLINES AND HELPLINES
___%
MEANS RESTRICTION
___%
¾
¾
¾
Public Awareness Campaigns
Outreach & Awareness Events
Outreach & Awareness Products
POLICIES AND PROTOCOLS FOR INTERVENTION AND
POSTVENTION
¾
¾
Policies and protocols related to intervention
Policies and protocols related to postvention
FINAL Product and Services Inventory (Campus)
11.31.2009
___%
___%
___%
___%
___%
___%
Page 29
Document A.2
COALITIONS AND PARTNERSHIPS
¾ Leading or substantially supporting a Suicide Prevention Coalition
¾ Participating in coalitions related to youth prevention
¾ Partnerships with agencies and organizations
OTHER SUICIDE PREVENTION STRATEGY
FINAL Product and Services Inventory (Campus)
11.31.2009
___%
___%
___%
___%
___%
Page 30
OMB No. 0930‐0286
Expiration Date: 05/31/10
Document F.4
Data Elements for the Training Exit Survey Cover Page - Campus
ariable Nam
estion Num
Grantee
Question
Text
Survey Submission Date
Randomly generated unique identifier
Text (System-generated date of submission into
the SPDC)
Month/Day/Year
Text
U_ID
SubDate
txsdate
1
txsid
2
txsnum
3
txsnum_un 4
txsname 5
txsfac
6
txszip
6
txssch
7
txssch1
7
txssch2
7
txsjj
7
txsjj1
7
txsjj2
7
txscw
7
Formats & Codes
Grantee
Training ID. Sites belonging to
Cohorts 1, 2 or 3 have 5 digit
txsids, of which the first two
digits are the site ID. Sites
belonging to Cohort 4 have 6
digit txsids, of which the first
three digits are the site ID.
Number of Trainees who
attended the training
Number of Trainees under 18
years of age who attended the
training
Name of Training
Name of facility where training
was held
Zipcode of facility where
training was held
Agency/Organization Affiliation
of Trainees: School
How many schools are
represented at the training?
How many of these schools
have participated in previous
trainings?
Juvenile Justice/Probation
Office/Detention Centers
Numeric
Numeric
Text
Text
Text
0=Not Endorsed
1=Endorsed
Numeric
Numeric
0=Not Endorsed
1=Endorsed
How many juvenile justice
related agencies/organizations
are represented at this training? Numeric
How many of these have
participated in previous
trainings?
Numeric
0=Not Endorsed
Child welfare/foster care
1=Endorsed
Document F.4
How many child welfare related
agencies/organizations are
represented at this training?
Numeric
txscw1
7
txscw2
7
txsmh
7
How many have participated in
previous trainings?
Numeric
0=Not Endorsed
Mental Health Agency
1=Endorsed
7
How many mental health
related agencies/organizations
are represented at this training? Numeric
txsmh1
txsmh2
7
txscbo
7
How many have participated in
previous trainings?
Numeric
0=Not Endorsed
Community‐based organization 1=Endorsed
txscbo1
7
How many community‐based
organizations are represented
at this training?
txscbo2
7
txsoth
txsotho
7
7
How many have participated in
previous trainings?
Numeric
0=Not Endorsed
Other type of organization
1=Endorsed
Other, Please Specify
Text
7
How many of these
organizations are represented
at this training?
7
How many have participated in
previous trainings?
Numeric
txsoth1
txsoth2
txsacttype 8
OMB No. 0930‐0286
Expiration Date: 05/31/10
Specify Activity Type
Numeric
Numeric
1=Educational Seminar/Student Orientation
2=Training (specify below)
Document F.4
OMB No. 0930‐0286
Expiration Date: 05/31/10
1=QPR (Question, Persuade, Refer)
2=Yellow Ribbon
3=ASIST (Applied Suicide Intervention Skills
Training)
4=Signs of Suicide (SOS)
5=Youth Depression & Suicide: Let’s Talk
6=SafeTALK
7=Frameworks
8=Suicide 101
9=Lifelines
10=AMSR (Assessing and Managing Suicide
Risk)
11=Teenscreen
12=Campus Connect
13=Other type of training
1=Gatekeeper training
2=Screener training
3=General awareness training
4=Clinical intervention/treatment training
5=Postvention training
6=Stress
Management
7= Faculty Training
8=Peer educator training 9=Alcohol/substance
abuse awareness
10=Diversity/Cultural
competency training
11=Academic
Success training
txsnewtype 9
Type of Training (select one)
txsnewtype 9
Other type of training (select
one)
txstot
txshr
9
10
1 =Yes
Is this a train‐the‐trainer event? 2=No
Duration of Training: Hour
Numeric
txsmn
10
Duration of Training: Minutes
Numeric
Document F.5
OMB No. 0930‐0286
Expiration Date: 05/31/10
MIS Required Variables
Percentage
Source of Data, Description, and Scope
Student Retention Rate - Percentage
of freshmen who started in Fall 2008
and returned in Fall 2009 (if you
cannot provide freshmen retention
rate, please explain what rate you are
providing in the source section)
Insert rows for additional
data/explanation
Number of Students
Receiving MH Services
Total Student Body
Enrollment AY 2008-2009
Source of Data, Description, and Scope
Number of Students
Receiving Emergency
Services
Total Student Body
Enrollment AY 2008-2009
Source of Data, Description, and Scope
Student Use of Mental Health Services
- Can include emergency mental
health services; unduplicated count of
all services if possible
Insert rows for additional
data/explanation
Student Use of Emergency Services Sources can include ER visits,
campus security responses, police
responses, mobile crisis units, etc. If
urgent care is not emergency, please
do not include.
Additional Element 1___________________________
Document F.5
Additional Element 2___________________________
Additional Element 3___________________________
Additional Element 4___________________________
OMB No. 0930‐0286
Expiration Date: 05/31/10
| File Type | application/pdf |
| File Title | PRODUCTS AND SERVICES INVENTORY |
| Author | Anupa |
| File Modified | 2010-05-19 |
| File Created | 2010-05-19 |