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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 10 minutes 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
Training Exit Survey
Thank you for participating in this survey about the training you just attended as part of the
Garrett Lee Smith Campus Suicide Prevention Cross-site Evaluation. This survey asks questions
about the training you just completed, what you plan to do with what you learned, and your
satisfaction with the training. Findings from this survey will help inform the Substance Abuse
and Mental Health Services Administration (SAMHSA) about suicide prevention activities.
Before you complete this survey, please read this consent form. The survey will take
approximately 10 minutes. By completing and returning this survey, you are consenting to
participate. Your participation in this survey is completely voluntary; there are no right or
wrong answers; and you may ask any questions that you have before, during or after you
complete the survey.
Privacy: Your answers to the survey questions will be kept private except as otherwise required
by law. Your name will not be linked with the information on your survey. The information that
we report to SAMSHA will not contain your name. Your name will not be used in any reports
about this evaluation.
Procedures: All participants in training activities funded as part of your Campus Suicide
Prevention Program are being asked to complete this survey. Therefore, your participation is
very important. The survey questions will ask you about your participation in [INSERT
TRAINING NAME].
Risks: There are few, if any, risks to you by completing this survey. You may stop the survey at
any time or not answer a question. You will not be penalized for stopping. If you stop the
survey, at your request, we will destroy your survey. Any questions that you have about this
survey will be answered before you start the survey.
TRAINING ID: PARTICIPANT ID:
Contact information: If you have any concerns about completing this survey or have any
questions about the study, please contact Christine Walrath, Principal Investigator, at 212-9415555 or [email protected].
In order to provide you with a copy of this consent form to take with you, please tear off
and keep the [color] copy, which is a copy of this consent form.
Thank you in advance for your willingness to participate.
Training Exit Survey
02.24.2010
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TRAINING ID: PARTICIPANT ID:
Thank you for your willingness to complete this survey. Your answers will help us
understand how trainings like the one you just completed can contribute to preventing
suicide among youth. Your answers are very important to us.
1.
Instructions: The main categories below represent different campus roles that you may identify with. Within each
primary role, is a list of secondary roles. Please FIRST select the primary role that best describes you, then
SECOND, within the primary role, please select the ONE ROLE best describes your role or affiliation at the
training.
For example, if you are a graduate student attending a training as part of your teaching assistant responsibilities, then
select “Student” as your primary role and within that role, you would select “Graduate teaching assistant”. If you
graduate student attending a training activity as a residential life advisor then select “Student” as your primary role
and within that role, you would select “Residential Life Advisor”.
Student
{ Disabled Student
{ Graduate teaching or research assistant
{ Intercollegiate Athlete
{ Mental Health/Psychology/Health Education
{
{
{
{
{
{
{
{
Concentration/Affiliation
Peer Counselor/Student Health worker
Researcher or program evaluator
Residential life advisor
Sorority/Fraternity Member
Student government/Organizations/Clubs
Teacher
Tutor/Learning Specialist
Veteran
Other Community Member
{ Community Group Member
{ Family Member/Caregiver
{ Relative
{ Volunteer (i.e. Big Brother/Big Sister, CASA, etc.)
{ Other - ___________________
Faculty/Instructor/Lecturer
{ Academic advisor
{ Administrative
{ Researcher or program evaluator
{ Researcher or program evaluator
{ Teaching
{ Tutor/Learning Specialist
Health Care Provider
{ Mental health or psychological counseling counselor
{ Other health professional
{ Primary care (e.g. physical/student health) provider
Staff
{ Administrative and Faculty Support Staff (e.g.,
{
{
{
{
{
{
{
academic affairs, finance, etc.)
Administrator (e.g., academic affairs, finance, etc.)
Athletic coach or trainer
Campus safety or other emergency response staff
Clergy/religious educator
Clerical/administrative support
Dean Provost
Facilities maintenance
Training Exit Survey
02.24.2010
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TRAINING ID: PARTICIPANT ID:
{ General Campus Support Staff (e.g., security,
nutrition, library)
{ Other Student Support Staff (e.g., registrar,
admissions, student life, etc.)
{ Residential life staff or advisor
{ Student Affairs
{ Tutor/Learning Specialist?
1. Please select the one primary role with which you most closely identify. For example, if you are a
faculty member who is also an administrator, choose the position that best matches your primary role
on campus. Were you required to participate in this training?
Yes
No
Don’t know
2. How do you intend to use what you learned during this training (select all that apply)?
Screen students for suicide behaviors (i.e., using a screening tool)
Publicize information about suicide prevention and mental health resources
Identify students who might be at risk for suicide
Provide direct services to students at risk for suicide and/or their families
Train others
Link students at risk of suicide with appropriate services or supports
Other (please describe:_______________________________)
Don’t intend to use what I learned
CURRENT CAMPUS…How do you intend to use what you learned during this training (select all
that apply)?
Screen youth for suicide behaviors (i.e., using a screening tool) (FROM S/T)
Formally publicize information about suicide prevention or mental health resources
Have informal conversations about suicide and suicide prevention with students and others
Identify students who might be at risk for suicide
Provide direct services to youth at risk for suicide and/or their families (FROM S/T)
Train other staff members
Make referrals to mental health services for at-risk students
Work with adult at-risk populations
Other (please describe:_______________________________)
Don’t intend to use what I learned
Please indicate your agreement with the following statements about the training.
1
Strongly
disagree
2
Disagree
3
Agree
4
Strongly
agree
3. The training increased my knowledge about suicide prevention.
4. The training materials I received (i.e. brochures, wallet cards,
etc.) will be very useful for my suicide prevention efforts.
5. The training met my needs.
6. The training addressed cultural differences in the students I
intend to serve (i.e., provided different cultural examples,
identified different cultures, etc.).
7. The training was practical to my life on campus.
8. I fully understand why I attended the training.
Training Exit Survey
01.16.2009
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5
N/A
TRAINING ID: PARTICIPANT ID:
9.
I am now more ready to help with suicide prevention on my
campus.
10. The things I learned will help prevent suicide or reduce the
problems that might lead to suicide (i.e., depression, substance
use, etc.).
On a typical day, about how much time do you spend interacting or talking directly with students?
0-15 minutes
15-30 minutes
30 minutes – 1 hour
1-2 hours
More than 2 hours
11.
How would you rate the training? (select one)
Below my skill level
At my skill level
Above my skill level
Don’t know
12. With whom do you expect to directly apply what you have learned during this training? (select all
that apply)
Students
Co-workers
Campus community members
Parents/foster parents/caregivers
Family/friends
Other (please describe: _____________________________)
*Participants will be asked to complete one of three training modules based on the type of
training they participated in (QPR/other brief gatekeeper training, AMSR/RRSR or Campus
Connect).
1. QPR AND OTHER BRIEF GATEKEEPER TRAININGS MODULE (also default
module for locally developed gatekeeper training if no local exit survey)
Now that you have received the QPR Gatekeeper training, please indicate how you would rate
your knowledge of suicide in the following areas?
16. Facts concerning Suicide Prevention:
Very Low
Low
Medium
High
Very High
17. Warning signs of suicide:
Training Exit Survey
01.16.2009
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TRAINING ID: PARTICIPANT ID:
Very Low
Low
Medium
High
Very High
18. How to ask someone about suicide:
Very Low
Low
Medium
High
Very High
19. Persuading someone to get help:
Very Low
Low
Medium
High
Very High
20. How to get help for someone:
Very Low
Low
Medium
High
Very High
21. Information about resources for help with suicide:
Very Low
Low
Medium
High
Very High
22. Please rate what you feel is the appropriateness of asking someone who may be at risk about
suicide.
Very Low
Low
Medium
High
Very High
23. What is the likelihood you will ask someone who appears to be at risk if they are
thinking of suicide?
Very Low
Low
Medium
Training Exit Survey
01.16.2009
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TRAINING ID: PARTICIPANT ID:
High
Very High
24. Please rate your level of understanding about suicide and suicide prevention.
Very Low
Low
Medium
High
Very High
This section contains a list of statements of what you may think or believe about suicide
prevention. Please read each statement and use the rating scale to indicate the degree to which
you agree or disagree with it. There are no right or wrong answers. It is important that you
answer all statements according to your beliefs and not what you think others may want you to
believe.
25. If someone I knew was showing signs of suicide, I would directly raise the question of
suicide with them.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
26. If a person's words and/or behavior suggest the possibility of suicide, I would ask the
person directly if he/she is thinking about suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
27. If someone told me they were thinking of suicide, I would intervene
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
28. I feel confident in my ability to help a suicidal person
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
29. I don't think I can prevent someone from suicide
Training Exit Survey
01.16.2009
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TRAINING ID: PARTICIPANT ID:
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
30. I don’t feel competent to help a person at risk of suicide
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Training Exit Survey
01.16.2009
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TRAINING ID: PARTICIPANT ID:
2. AMSR AND RRSR MODULE (also default module for other clinical training if no
locally-developed exit survey)
Please rate the extent to which the workshop increased your knowledge in the following
areas:
1. Managing one’s own reactions to suicide.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
2. Reconciling the difference (and potential conflict) between the clinician’s goal to prevent
suicide and the client’s goal to eliminate psychological pain via suicidal behavior.
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
e.
3. Eliciting suicide ideation, behavior, plans and intent.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
4. Collaboratively developing a crisis response plan.
a.
b.
c.
d.
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
5. Developing a written treatment and services plan that addresses the client’s immediate,
acute, and continuing suicide ideation and risk for suicide behaviors
a.
Increased knowledge very much
b.
Increased knowledge somewhat
c.
Knowledge remained the same
d.
Not sure
6. Developing policies and procedures for following clients closely, including taking
reasonable steps to be proactive.
a.
b.
c.
d.
Training Exit Survey
01.16.2009
Increased knowledge very much
Increased knowledge somewhat
Knowledge remained the same
Not sure
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TRAINING ID: PARTICIPANT ID:
Section II: Suicide Prevention Self-Efficacy
1) I am able to maintain a collaborative, non-adversarial stance by creating an atmosphere in
which the client feels safe in sharing information about suicidal thoughts, behaviors and
plans
Expert 10
9
8
7
6
5
4
3
2
1 Novice
2) I am able to demonstrate an understanding of suicide-related risk and protective factors by
asking questions about suicide-related risk and protective factors during assessment.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
3) I am able to collect accurate assessment information about suicide-related risk by eliciting
risk and protective factors during the clinical interview and obtaining records and
information from collateral sources as appropriate.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
3
2
1 Novice
4) I am able to identify warning signs of acute risk of suicide.
Expert 10
9
8
7
6
5
4
5) I am able to integrate a risk assessment for suicidality into a clinical interview
Expert 10
9
8
7
6
5
4
3
2
1 Novice
6) I am able to document assessment information from a bio-psycho-social and cultural
perspective
Expert 10
9
8
7
6
5
4
3
2
1 Novice
7) I am able to demonstrate an understanding of suicide-related risk and protective factors by
considering all relevant factors when formulating risk
Expert 10
9
8
7
6
5
4
3
2
1 Novice
8) I am able to collect accurate assessment information about suicide-related risk by eliciting
suicide ideation, behavior and plans and warning signs of acute risk
Training Exit Survey
01.16.2009
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TRAINING ID: PARTICIPANT ID:
Expert 10
9
8
7
6
5
4
3
2
1 Novice
9) I am able to make a clinical judgment of risk that a client will attempt or complete suicide in
the short and long term by working collaboratively with other professionals in an interdisciplinary team approach to integrate and prioritize all the information that has been
collected, including a consideration of developmental, cultural and gender-related issues
related to suicidality.
Expert 10
9
8
7
6
5
4
3
2
1 Novice
10) I am able to document formulation of risk, including interaction with professional colleagues,
and write a sound rationale for clinical judgment.
Expert 10
Training Exit Survey
01.16.2009
9
8
7
6
5
4
3
2
1 Novice
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TRAINING ID: PARTICIPANT ID:
3. Campus Connect Module
Section I: Suicide Prevention Knowledge and Self-Efficacy
Not at all
True
1.
I understand the meaning of
various suicide terms
(i.e., threat, attempt, survivor of
suicide).
Somewhat
True
Very
True
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5 6
7
8
9
10
3. I am aware of the various
risk factors related to suicide.
1
2
3
4
5
6
7
8
9
10
4. I know how to ask someone
if they are thinking about suicide.
1
2
3
4
5
6
7
8
9
10
5. I understand the potential
impact of paraphrasing emotions.
1
2
3
4
5
6
7
8
9
10
6. I am familiar with the available
referral resources for emotionally
distressed students.
1
2
3
4
5
6
7
8
9
10
7.
I feel comfortable asking
1
someone if they are thinking about suicide.
2
3
4
5
6
7
8
9
10
8.
I feel comfortable paraphrasing
emotions..
1
2
3
4
5
6
7
8
9
10
9. I believe I am able to emotionally
connect with students in crisis.
1
2
3
4
5 6
7
8
9
10
10. I feel comfortable attempting to
emotionally connect with students
in crisis.
1
2
3
4
5
6
7
8
9
10
11. I feel capable of helping students in
1
2
3
4
5
6
7
8
9
10
2. I am familiar with the
prevalence rates of suicidal ideation
and suicide attempts among college
students.
Training Exit Survey
01.16.2009
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TRAINING ID: PARTICIPANT ID:
crisis feel understood.
12. I feel able to assist emotionally
distressed students in accessing available
referral resources.
1
2
3
4
5
6
7
8
9
10
13. I believe that distressed students
will follow through with referrals I
provide to them.
1
2
3
4
5
6
7
8
9
10
Background Information
13.
14.
What is your gender?
Female
Male
Transgender
Other
What is your age? years
15. Are you Hispanic or Latino (select one)?
Yes
No
17a.
If Yes, Which group represents you? Are you… (select one or more)
Mexican, Mexican-American, or Chicano
Puerto Rican
Cuban
Dominican
Central American
South American
16. What is your race (select one or more)?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
This is the end of the survey.
Thank you for taking the time to complete this survey. Your participation is critical to the
success of the Garrett Lee Smith Memorial Suicide Prevention Cross-Site Evaluation.
Training Exit Survey
01.16.2009
Page 13
| File Type | application/pdf |
| File Title | Trainers |
| Author | Angela.K.Sheehan |
| File Modified | 2010-05-19 |
| File Created | 2010-05-19 |