Form D3 TUP-S Verbal Co D3 TUP-S Verbal Co D3 TUP-S Verbal Consent Script

OMB No. 0930-0286

Expiration Date: XXXX-XXXX

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 respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS) State/Tribal Youth Suicide Prevention and Early Intervention Programs

Training Utilization and Preservation–Survey

State/Tribal 6-Month Follow-up and Verbal Consent

Hello, my name is [INSERT INTERVIEWER NAME], and I'm calling to talk to you about the training that you attended on [INSERT TRAINING DATE]. Is now a good time for me to give you more information?

IF NO: Is there a better time to call back?

IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for ICF, a company that has been contracted to conduct a cross-site evaluation of suicide prevention programs funded by SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration). As part of this evaluation, we are interviewing a random sample of people who have attended a campus suicide prevention trainings. We hope to learn more about the trainings, how you have used what you learned, and the impact of the training on you and your interactions with your peers.

On [DATE OF TRAINING] you participated in a training called [INSERT TRAINING NAME], as part of the Garrett Lee Smith Memorial (GLS) Campus State/Tribal Youth Suicide Prevention and Early Intervention Program. You participated in follow-up survey about 3 months ago. At the end of the survey you consented to be contacted again in 3 months for an additional follow-up survey. We are contacting you now to administer the survey. We are contacting you now to administer the survey. This survey asks questions about the training, what you plan to do with what you learned during the training, and your satisfaction with the training. Findings from this survey will help inform SAMHSA about suicide prevention activities.

The survey will take approximately 10 minutes to complete and you will receive $10 for your participation. If you are interested, I will give you some more information and get your verbal consent.

Before I ask you whether you agree to be interviewed, there are a few more things that you should know:

Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary. There are no penalties or consequences for not participating. You can choose to stop the interview at any time, or not answer a question, for whatever reason. If you stop the interview, at your request, we will destroy the survey. You may ask any questions that you have before, during, or after you complete the survey. May I continue?

Privacy: Your answers are private and will not be linked to your name. Your name will never appear in any report that summarizes the findings of the cross-site evaluation. All findings will be reported in aggregate; this is, they will be combined with responses from other individuals.

Additional Protection: In addition, to protect the information that you give us, we have applied for a Certificate of Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate of Confidentiality will protect the members of the research staff from being forced, even under a subpoena, to release any information in which you are identified. Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or information regarding imminent danger to yourself or others, which we will report to the appropriate local and state agency. Additionally, DHHS may see your information if we are audited. Finally, the certificate of confidentiality does not imply the endorsement or the disapproval of the DHHS.

Risks: Completing this interview poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a question, for whatever reason. You will not be penalized for stopping. You can contact the evaluation team lead in charge of this survey at any time. If you stop the interview, at your request, we will destroy your survey.

Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national effort to prevent suicide.

I am not an expert in the subject matter, and I do not work for the people who provided the training, so you can't hurt my feelings and there aren't any wrong answers. We're just interested in your thoughts and opinions.

Compensation: You will receive $10 for participating in this survey.

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) 941-5555 or [email protected].

Do you have any questions?

Do you agree to participate in this interview?

IF YES, continue.

Thank you in advance for your willingness to participate. This call may be recorded and/or monitored for quality assurance purposes.

Part I. Great, thanks. To begin, I’m going to ask you some questions about the knowledge you gained at the training. (Training Knowledge)

1. About 6 months ago, you participated in [INSERT TRAINING NAME], a training regarding suicide prevention, correct?

Six months ago was [today’s date – 6 months].

• Yes

• No

2. Now that it has been about 6 months since your training, we want to know how well you think the [INSERT TRAINING NAME] has helped in your work, home, or community.

[Interviewer Instructions: If asked, the setting of interest is the one where they are most likely to use their training]

For each of the following statements, please tell me if you Strongly agree, Agree, Disagree, or Strongly disagree.

[IF NECESSARY: Please tell me if you Strongly agree, Agree, Disagree, or Strongly disagree.]

Please rate the following statements about [INSERT TRAINING NAME],

	1 Strongly disagree	2 Disagree	3 Agree	4 Strongly agree	5 N/A/No opinion
a. The training increased my knowledge about suicide prevention.
b. The training materials I received (i.e., brochures, wallet cards) have been very useful for my suicide prevention efforts.
c. The training has met my suicide prevention needs.
d. The training addressed cultural differences in the youth I serve.
e. The training has proven practical to my work and/or my daily life.
f. I have used my training to help with youth suicide prevention in my community.
g. The things I learned during the training have helped me prevent youth suicide or reduce the problems that might lead to suicide (i.e., depression, substance use).

3. In the last three months have you used your training to: (Please select all that apply):

Three months ago was [today’s date – 3 months].

• Screen youth for suicide behaviors (i.e., using a screening tool)

• Formally publicize information about suicide prevention or mental health resources

• Have informal conversations about suicide and suicide prevention with youth and others

• Identify youth who might be at risk for suicide

• Provide direct services to youth at risk for suicide and/or their families

• Train other staff members

• Make referrals to mental health services for at risk youth

• Work with adult at-risk populations

• Other (please describe:_______________________________)

• Don’t intend to use what I learned

4. Many suicide prevention trainings also focus on developing life skills and identifying positive aspects of life that reduce the likelihood of suicide. We would like to know how well you think [INSERT TRAINING NAME] enhanced your ability to identify strengths for yourself and others in your work, home, or community. [Interviewer Instructions: If asked, the setting of interest is the one where they are most likely to use their training]

For each of the following statements, please tell me if you Strongly agree, Agree, Disagree, or Strongly disagree.

Please rate the following statements about [INSERT TRAINING NAME].

	1 Strongly disagree	2 Disagree	3 Agree	4 Strongly agree	5 N/A/No opinion
a. The training has helped me develop stronger social and familial relationships.
b. The training has helped me connect to members of the community.
c. As a result of the training, I place greater value on connections to friends and family.
d. The training showed me the importance of high self-esteem and self-confidence.
e. As a result of the training, I am more aware of the importance of communication.
f. As a result of the training, I have a greater sense of competence.
g. As a result of the training, I have a stronger sense of well-being.

5. Please indicate how you would rate your knowledge of suicide in the following areas.

For each of the following statements, please tell me how you would rate your knowledge, very high, high, low, or very low.

	1 Very low	2 Low	3 High	4 Very high	5 N/A/No opinion
a. Facts concerning suicide prevention.
b. Warning signs of suicide.
c. How to ask someone about suicide.
d. Persuading someone to get help.
e. How to get help for someone.
f. Information about resources for help with suicide.
g. Please rate what you feel is the appropriateness of asking someone who may be at risk about suicide.
h. What is the likelihood you will ask someone who appears to be at risk if they are thinking of suicide?
i. Please rate your level of understanding about suicide and suicide prevention.

Part III. This set of questions asks about your posttraining behaviors.

6. In the last 3 months have you used your training to train adults to intervene with a youth at risk for suicide?

Three months ago was [today’s date – 3 months].

• Yes

• No

[If No, skip to #5b]

1. [If Yes] About how many?

• 1–5

• 6–10

• 11–20

• >20

2. In the past 3 months have you used your training to train youth to intervene with a peer at risk for suicide?

• Yes

• No

[Interviewer instructions: If asked, youth are aged 10–24]

[If No, skip to #6]

3. [If Yes] About how many?

• 1–5

• 6–10

• 11–20

• >20

7. In the past 3 months, have you used [INSER TRAINING NAME] to identify youth you thought might be at risk for suicide?

Three months ago was [today’s date – 3 months].

• Yes

• No

[Interviewer instructions: If asked, this should be based on what they learned during their training; if asked, youth are ages 10–24]

[If No, skip to question 14]

1. [If Yes] In the past 3 months, about how many youth have you identified?

• 1–5

• 6–10

• 11–20

• >20

2. In which of the following settings were they identified? Please select all that apply.

• School

• Child welfare agency

• Juvenile justice agency

• Law enforcement agency

• Physical health agency (e.g., primary care, pediatrician’s office)

• Emergency Response Unit or Emergency Room

• Mental health agency

• Community-based Organization, Recreation, or After School Activity

• Home

• Digital medium (e.g., Facebook or text message)

• Other (please describe: __________________________________)

3. What was the setting where most of these identifications were made? Please select all that apply.

• School

• Child welfare agency

• Juvenile justice agency

• Law enforcement agency

• Physical health agency (e.g., primary care, pediatrician’s office)

• Emergency Response Unit or Emergency room

• Physical health agency

• Mental health agency

• Community-based Organization, Recreation, or After School Activity

• Home

• Digital medium (e.g., Facebook or text message)

• Other (please describe: __________________________________)

8. Okay, to what services, resources, or individuals did you refer the youth you identified? (Select all that apply.)

• Mental health agency

• Psychiatric hospital/unit

• Emergency room

• Substance abuse treatment center

• School counselor

• Private mental health practice

• Mobile crisis unit

• Other (please describe: ______________________________________)

9. Do you know whether the youth received the services to which they were referred?

• Yes

• No

1. [If No] Why don’t you know if the youth received services? Then skip to item #14

2. [If Yes] Think about the youth referred. In the past 3 months, about how many of the youth you referred to services actually received those services?

• All (100%)

• Almost all (76–99%)

• Most (51–75%)

• Some (26–50%)

• A few (1–25%)

• None (0)

Now, think back to the most recent youth you identified and who actually received services—

	1 Very satisfied	2 Satisfied	3 Neutral	4 Somewhat satisfied	5 Not at all satisfied
9. How satisfied are you that your training and the actions you took on the basis of your training were appropriate and effective?

10. Thinking about this same youth, about how many days did it take from the time you made the referral to when they received their first service?

[Interviewer instructions: If asked, services could include mental health assessment/treatment; substance use assessment/treatment; psychiatric hospitalization; emergency room or mobile crisis]

• Less than 1 day

• Less than 1 week

• Between 1 and 2 weeks

• Between 3 and 4 weeks

• More than 1 month

11. Again, thinking about this same youth, what was the first service he or she received?

• Mental health assessment

• Substance use assessment

• Mental health counseling

• Substance abuse counseling

• Psychiatric services or medication management without therapy

• Inpatient or residential psychological services

• Other service (Please describe: _______________________________)

10. Did he or she receive any additional mental health services since that first appointment?

• Yes

• No

[If No, skip to #14]

1. [If yes] What were they?

• Mental health assessment

• Substance use assessment

• Mental health counseling

• Substance abuse counseling

• Inpatient services

• Family therapy

• Group therapy

• Medication

• Other service (Please describe: _______________________________)

• Don’t know

Part IV. Great, thanks! The following questions are about how easy or difficult it has been to implement what you learned in the past 3 months in your training in your community, home, or workplace.

	1 Not supportive at All	2 Somewhat supportive	3 Very supportive	4 No opinion
13. How supportive has your community or workplace been of implementing what you learned through the [INSERT TRAINING NAME]?

14. Of the following issues, what is the greatest facilitator of implementing youth suicide prevention in your community or workplace?

• Training/professional development opportunities

• Increased community awareness

• Community resources

• Community collaboration

• State, tribe, or agency prioritization of suicide prevention

11. Of the following issues, what is the greatest barrier to implementing youth suicide prevention in your community or workplace?

• Access to appropriate services

• Lack of awareness about the problem of suicide

• Time constraints

• Workplace characteristics

• Lack of funding

12. Our final set of questions are about your personal background. We would like you to identify the primary settings in which you might interact with youth. Within each setting, we will ask you about the different professional or volunteer role that BEST describes you. You can only select one setting and one role.

1. Please indicate the primary setting in which you interact with youth:

• Education (K-12)

• Substance abuse

• Juvenile justice/probation

• Emergency response

• Higher education (college/university)

• Tribal services/tribal government

• Child welfare

• Mental health

• Primary health care (other than mental health)

• Other community settings

• DK

• REFUSED

2. Please select the professional or volunteer role that BEST describes you within your setting:

Education (K–12) Teacher School administrator Mental health clinician/counselor/psychologist Social worker/case worker/care coordinator Emergency/crisis care worker Program evaluator Administrative assistant/clerical support personnel Academic advisor Tutor Other: ___________________ Substance abuse Program/system administrator Mental health clinician/counselor/psychologist Social worker/case worker/care coordinator Emergency/crisis care worker Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Juvenile justice/probation Program/system administrator Probation officer Social worker/case worker/care coordinator Detention facility guard Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Emergency response Police officer or other law enforcement staff Program/system administrator Emergency medical technician Fire fighter Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Higher education (college/university) Faculty/professor/researcher Administrator (e.g., dean’s office, vice president, provost) Residential life staff Mental health clinician/counselor/psychologist Social worker/case worker/care coordinator Emergency/crisis care worker Program evaluator Administrative assistant/clerical support personnel Student Other: ___________________

Tribal services/tribal government Traditional tribal healer Tribal elder Elected tribal official Program/system administrator Mental health clinician/counselor/psychologist Social worker/case worker/care coordinator Community outreach worker Emergency/crisis care worker Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Child welfare Program/system administrator Mental health clinician/counselor/psychologist Social worker/case worker/care coordinator Emergency/crisis care worker Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Mental health Program/system administrator Mental health clinician/counselor/psychologist Social worker/case worker/care coordinator Emergency/crisis care worker Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Primary health care (other than mental health) Program/system administrator Physician Nurse Nursing assistant/health technician Program evaluator Administrative assistant/clerical support personnel Other: ___________________ Other community settings Parent or foster/resource parent Other caregiver Relative Youth mentor Volunteer (i.e., Big Brother Big Sister, CASA) Youth advocate Clergy/religious educator Other: ___________________

13. What is your job title?

14. On a typical day, about how much time do you spend interacting or talking directly with youth? (Select one)

[Interviewer instructions: If asked, youth are aged 10–24]

• 0–15 minutes

• 16–30 minutes

• 310 minutes–1 hour

• 1–2 hours

• More than 2 hours

15. What is the nature of the work that you do with youth?

• Teaching

• Counseling/advising

• Providing mental health services

• Case management (e.g., child welfare, juvenile justice)

• Mentoring

• No formal work; interactions with youth are intermittent within the community setting

16. Have you received any booster trainings in suicide prevention in the last 3 months?

• Yes

• No

20 a. If yes, which training(s) have you received?

_________________________________________________________________

Thank you very much for your time today. Your information will be very valuable to SAMHSA in its efforts to reduce suicide among youth. If you have any questions or concerns about this survey, please contact Gingi Pica, ICF Macro, at (212) 941-5555.

Training Utilization and Preservation–Survey: State Tribal 6-Month Follow-up Page 17