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 Program
Training Utilization and Preservation–Survey
Adolescent Version (TEXT)
About three months ago you participated in a training activity related to suicide prevention. At the end of the activity, you and your caregiver/parent/guardian consented to be contacted for a follow-up survey about your experience.
About the survey
We are inviting you and a random sample of youth who participated in training activities related to suicide prevention to participate in the study because we want to understand what you learned during this training, how you are using what you learned, and if it has changed the way you talk with your peers. Your participation in this survey is completely voluntary and you may end the survey at any time for any reason. You will not be penalized for stopping.
This survey will take about 10 minutes and will be done through text messages to your cell phone. As a thank you, we will give you a $10 Amazon gift code.
Some of the questions may make you feel uncomfortable. You do not have to answer any questions you do not want to answer. You may stop the survey at any time, or not answer a question, for whatever reason. If you stop the survey, at your request, we will destroy your survey. You will not be penalized for stopping or not answering a question.
Your participation will not result in any direct benefits to you, but you will be contributing to an effort to prevent suicide among youth.
Your answers will be combined with other youth’s answers and your name will never be used. Your answers to the questions will be private. You will not receive any spam/unsolicited text messages and your phone number will not be shared. We will not share your responses with your name. All of our reports combine many people’s responses so no one can be identified.
We have applied for a Certificate of Confidentiality (CC) from the U.S. Department of Health and Human Services (DHHS) to keep anything that you tell us private. This means that we will not tell anyone what you tell us even if a judge tries to force us to identify you as a person in the study. You should know, however, that we may tell local authorities if harm to you, harm to others, or if child abuse/neglect becomes a concern. Also, the government agency that has provided the money for this project may see your information if they ask for our records to ensure we were conducting the project correctly. The CC that we have does not mean that DHHS approves or disapproves this project.
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].
If you or someone you know is in need of help or you just want to learn more about suicide prevention, please call the National Suicide Prevention Lifeline at (800) 273-TALK (8255).
Please respond YES by text if you would like to continue receiving survey questions via text message.
OPTION 1—Text Message Survey
Short Message Service Questions – 1
Opt in
ICF is conducting an important survey of suicide prevention trainings. You will get a $10 Amazon gift code for participating. Text “yes” for more.
Preliminary Survey Text Messages
Text “Stop” at any time to end. Respond only when you are not driving or in another situation where it is dangerous to text. Contact [email protected] for help.
Go [enter URL] to review the survey consent.
All responses are confidential. Do you consent to participate in a 5-item survey about suicide prevention? Text 01 = Yes, 02 = No
Text Survey Begins
You participated in the [INSERT NAME OF TRAINING] on [INSERT TRAINING DATE], correct? Text 01 = Yes, 02 = No
Do you agree with this: this training increased my knowledge about suicide prevention. Text 01= Strongly Agree, 02 = Agree, 03 = Disagree, 04 = Strongly Disagree
Do you agree with this: I feel confident in my ability to help a suicidal person. Text 01= Strongly Agree, 02 = Agree, 03 = Disagree, 04 = Strongly Disagree
The next 2 items are about suicide. You make skip questions you do not want to answer.
During the past 12 months, did you ever seriously consider attempting suicide?
Text 01 = Yes, 02 = No, 999 = Skip
During the past 12 months, how many times did you actually attempt suicide?
Text 00 = 0, 01 = 1, 02 = 2-3, 03 = 4-5, 04 = 6 or more, 999 = Skip
Thank you for your help with this survey. Your Amazon gift code is XXXXXXXXXXXXXXX. Please send any questions or concerns to [email protected]. To talk with a counselor call the National Suicide Prevention Lifeline at 1-800-273-8255, 24/7.
Short Message Service Questions – 2
Opt in
ICF is conducting an important survey of suicide prevention trainings. You will get a $10 Amazon gift code for participating. Text “yes” for more.
You participated in the [INSERT NAME OF TRAINING] on [INSERT TRAINING DATE], correct? Text 01 = Yes, 02 = No
Do you agree with this: this training increased my knowledge about suicide prevention. Text 01= Strongly Agree, 02 = Agree, 03 = Disagree, 04 = Strongly Disagree
Do you agree with this: I feel confident in my ability to help a suicidal person. Text 01= Strongly Agree, 02 = Agree, 03 = Disagree, 04 = Strongly Disagree
Have you used the training to identify youth at risk for suicide? Text 01 = Yes, 02 = No
Do you know whether the people you identified received help from anyone? Text 01 = Yes, 02 = No
Thank you for your help with this survey. Your Amazon gift code is XXXXXXXXXXXXXXX. Please send any questions or concerns to [email protected]. To talk with a counselor call the National Suicide Prevention Lifeline at 1-800-273-8255, 24/7.
Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS)
State/Tribal Youth Suicide Prevention and Early Intervention Program
Training Utilization and Preservation–Survey
Adolescent Version (WEB SURVEY & CONSENT)
OPTION 2—Web Survey
About three months ago you participated in a training activity related to Suicide prevention. At the end of the activity, you and your caregiver/parent/guardian consented to be contacted for a follow-up survey about your experience. Is that correct?
01 Yes
02 No (exit)
About the Survey
We are inviting you to participate in the survey because we want to understand what you learned during this training, how you are using what you learned, and if it has changed the way you talk with your peers. Your participation in this survey is completely voluntary and you may end the survey at any time for any reason. You will not be penalized for stopping.
The survey will take 10 minutes to complete. As a thank you after the survey, we will give you a $10 Amazon gift code.
Some of the questions may make you feel uncomfortable. You do not have to answer any questions you do not want to answer. You may stop the survey at any time, or not answer a question, for whatever reason. You will not be penalized for stopping or not answering a question.
Your participation will not result in any direct benefits to you, but you will be contributing to an effort to prevent suicide among youth.
Your answers will be combined with other youth’s answers and your name will never be used. Your answers to the questions will be private. We will not share your responses with your name. All of our reports combine many people’s responses so no one can be identified.
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].
If you or someone you know is in need of help or you just want to learn more about suicide prevention, please call the National Suicide Prevention Lifeline at (800) 273-TALK (8255).
If you agree to take this survey, please click “I AGREE” below. If not, please click “I DO NOT AGREE.”
“I AGREE” (Move to next Web page to start the survey.)
“I DO NOT AGREE” (Move to the Web page which should say “Thank you for your time in considering participation in the TUP Adolescent Survey. Please contact the principal investigator, Christine Walrath, at 212-941-5555 with any questions,” and offer respondents an opportunity to go to the survey homepage.)
Thank you!
Q1.2
Now that it has been about 3 months since your training, we would like to know how well you think the [restore name of training from sample] training has helped you. For each of the following statements, please mark if you Strongly agree, Agree, Disagree, or Strongly disagree.
The training increased my knowledge about suicide prevention.
The training materials I received (such as brochures, wallet cards, etc.) have been very useful for my suicide prevention efforts.
The training has met my suicide prevention needs.
The training addressed the needs of young people like me.
I have been able to use this information in my life.
The things I learned during the training have helped me prevent youth suicide or reduce the problems that might lead to suicide (such as depression or alcohol and drug use).
01 Strongly agree
02 Agree
03 Disagree
04 Strongly disagree
Q1.3
Have you used the //restore name of training// training to do any of the following?
Ask young people about suicide?
Share information about suicide prevention or with mental health resources
Talk to other people about suicide and suicide prevention
Identify youth who might be at risk for suicide
Something else (specify)
01 Yes
02 No
Q1.4
Now that you have received this training, please indicate how you would rate your knowledge of suicide in the following areas. Please mark very high, high, low, or very low?
Facts concerning Suicide Prevention.
Warning signs of suicide.
How to ask someone about suicide.
Persuading someone to get help.
How to get help for someone.
Information about resources for help with suicide:
Please rate what you feel is the appropriateness of asking someone who may be at risk about suicide.
What is the likelihood you will ask someone who appears to be at risk if they are thinking of suicide?
Please rate your level of understanding about suicide and suicide prevention.
01 Very high
02 High
03 Low
04 Very low
Q2.1
How well did the //restore name of training from sample// training prepare you to help young people who may be at risk for suicide in your work, home, or community?
01 Prepared very well
02 Prepared somewhat
03 Prepared not at all
Q2.2
Below is a list of statements you may think or believe about suicide prevention. It is important that you answer all statements according to your beliefs and not what you think others may want you to believe.
Please mark if you strongly agree, agree, disagree, or strongly disagree?
If someone I knew was showing signs of suicide, I would directly ask them about suicide.
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.
If someone told me they were thinking of suicide, I would try to get them some help.
I feel confident in my ability to help a suicidal person.
I don't think I can prevent someone from suicide.
I don’t feel competent to help a person at risk of suicide.
01 Strongly agree
02 Agree
03 Neutral
04 Disagree
05 Strongly disagree
Q3.3
Have you used the //restore name of training from sample// training to identify youth ages 10-24 you thought might be at risk for suicide?
01 Yes
02 No
Q3.3a
About how many youth did you identify?
01 1-5
02 6-10
03 11-20
04 >20
//ask if Q3.3=01//
Q3.3d
Did you talk to anyone about the person you identified as at risk for suicide?
01 Yes
02 No
Q3.4
What type of person did you talk to the most?
(Select all that apply.)
01 School guidance counselor or social worker
02 Peer counselor
06 Health care provider
07 Teacher
09 Family Member
97 Some other trusted adult (SPECIFY)
Q3.5
Do you know whether the people you identified received help from the person you talked with?
01 Yes
02 No
//ask if Q3.5=01//
Q3.5a
Thinking about the young people you identified at risk for suicide, about how many do you think got help?
01 All (100%)
02 Almost all (76-99%)
03 Most (51-75%)
04 Some (26-50%)
05 A few (1-25%)
06 None (0%)
//ask if Q3.5=01//
Q3.6
Now, think back to the most recent youth you identified—how satisfied are you that your training and the actions you took based on your training were appropriate and effective?
01 Very satisfied
02 Somewhat Satisfied
03 Neither satisfied nor dissatisfied
04 Somewhat dissatisfied
05 Very dissatisfied
The next 2 items are about suicide. You make skip questions you do not want to answer. To talk with a counselor please call the National Suicide Prevention Lifeline at 1-800-273-8255, 24/7.
Q3.7
During the past 12 months, did you ever seriously consider attempting suicide?
01 Yes
02 No
999 Skip
Q3.8
During the past 12 months, how many times did you actually attempt suicide?
00 = 0
01 = 1
02 = 2-3
03 = 4-5
04= 6 or more
999 = Skip
Q4.1
How supportive has your community been of implementing what you learned through the //restore name of training from sample// training? Would you say they are very supportive, somewhat supportive, or not supportive at all?
01 Very supportive
02 Somewhat supportive
03 Not supportive at all
Which of the following terms best describes your role in suicide prevention in your community, are you a
65 Peer counselor
66 Baby sitter/child caregiver
68 Youth mentor
69 Community volunteer (church, YMCA)
Q6. What is your gender?
01 Female
02 Male
03 Transgender
04 Other
Q7. What is your age?
Q8. Are you Hispanic or Latino?
01 Yes
02 No
//ask if Q8=1//
Q8.1 If yes, which group represents you?
(Select all that apply.)
01 Mexican, Mexican American, or Chicano
02 Puerto Rican
03 Cuban
04 Dominican
05 Central American
06 South American
Q9. What is your race?
(Select all that apply.)
01 American Indian or Alaska Native
02 Asian
03 Black or African American
04 Native Hawaiian or other Pacific Islander
05 White
//ask if Q1.1=1,2//
Outro
//ask if Outro=01//
AMAZON
Your Amazon gift code number is: //insert gift code number from program//.
Thank you very much for your time today. Your information will be valuable to in its effort to reduce suicide among youth. If you have any questions or concerns about this survey, please contact Christine Walrath, principal investigator, at 212-941-5555.
To talk with a counselor call the National Suicide Prevention Lifeline at 1-800-273-8255, 24/7.
Training
Utilization and Preservation–Survey: Adolescent SMS Versions 1
& 2 Page
09.27.13
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | gsgro |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |