Form E. RNS Instrument E. RNS Instrument E. RNS Instrument and 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 40 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

Referral Network Survey and Verbal Consent Script

Description of Participation

The survey asks about your organization’s involvement in your local suicide prevention referral network (we are contacting all organizations in the local referral network). This survey is being conducted to better understand the early identification and referrals of youth at risk for suicide in your community. Participation is completely voluntary and you can exit from the survey at any time or refuse to answer any question.

Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary. There are no penalties or consequences to you or your organization for not participating. You can choose to 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 the survey. You may ask any questions that you have before, during, or after you complete the survey.

The survey will take approximately 40 minutes

Privacy: All responses will be kept completely confidential. Contact information will be entered into a password-protected database which can only be accessed by a limited number of individuals (selected ICF staff) who require access. These individuals have signed confidentiality, data access, and use agreements. Your name will not be used in any reports, but it is possible that your agency and/or organization and the information you provide about your agency or organization may be identifiable when reporting results.

Benefits: Your participation will not result in any direct benefits to you. However, your input will help to provide a better understanding of the systems and networks in place to help youth identified at risk for suicide in your community. The findings will assist in informing the Substance Abuse and Mental Health Services Administration (SAMHSA) about suicide prevention activities and network processes. However, your findings will assist in informing SAMHSA will contribute suicide prevention activities and network processes.

Risks: This survey poses few, if any, risks to you and/or your organization. However, it is possible that your agency and/or organization and the information you provide about your agency or organization may be identifiable when reporting results.

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].

Please click the "I CONSENT" box below to proceed to the survey.

• I CONSENT

• I DO NOT CONSENT

Organization

1. What is the primary classification for your agency or organization? (Select only one.)

   01	Mental health/behavioral health agency		10	Tribal health agency
   02	Child welfare services (i.e., social services) agency		11 12	Tribal social service agency Tribal government
   03	K-12 school		13	College or university
   04 05 06 07 08 09	Juvenile justice agency Police/Law enforcement agency State health department agency Local health department agency Primary care providers Crisis center		14 15 16 95 97 99	Nonprofit community service organization Individual therapist Religious or spiritual organization Other Don’t know Not applicable

2. About how many staff members (full-time and part-time) are employed by your organization? If you are the only employee, indicate 001.

__ __ __ Number of staff members

97 Don’t know

3. What are the services available from your organization for youth who have attempted or are at risk of suicide? (Select all that apply.)

01	Emergency services		09	Family therapy
02	Safety planning		10	Inpatient or residential services
03	Mental health assessment		11	Support groups
04	Substance use assessment		12	Provide referrals to direct services
05	Mental health counseling		95	Other services
06	Substance abuse counseling		97	Don’t know
07	Medication management		99	Not applicable
08	Individual therapy

3a. [IF 3 IS 01-11] Within the last year, approximately how many suicidal youth have been evaluated and/or treated at your organization?

1. None

2. One

3. 2 to 10

4. 11 or more

97 Don’t know

99 Not applicable

4. Does your organization provide training/crisis education opportunities related to suicide prevention for the staff?

   01	Yes
   02	No
   97	Don’t know
   99	Not applicable

5. How frequently are training/ crisis education opportunities related to suicide prevention made available to the staff?

01	Never
02	Rarely (less than once a year)
03	Sometimes (1 to 3 times a year)
04	Frequently (more than 4 times a year)
97	Don’t know
99	Not applicable

Respondent

6. What is your primary professional role?

01 02 03	Social worker Licensed Marriage and Family Therapist Clinical or Counseling Psychologist
04 05	Medical Doctor/ Primary Physician Nurse
06	School Psychologist
07	Guidance Counselor/ School Counselor
08	Teacher
09 10	Principal Other School Staff
11	Volunteer
12 13 14 15	Law Enforcement officer Probation Officer Medical Doctor/ Primary Physician Religious/ Spiritual Leader
16 17	Management (CEO, CFO, CIO, Project Manager/Director, etc.) Tribal Leader
95	Other, please specify: __________________________________
99	Not applicable

7. What is your highest level of education?

01	High school
02	Two-year college or technical program
03	Bachelor’s level
04	Master’s level
05	Doctoral level
99	Not applicable

8. Are you the primary point of contact at your organization that is familiar with the organizational response to youth at risk for suicide?

01		Yes
02		No
97		Don’t know
	8a. [IF NO or DON’T KNOW] Do you feel that you are the appropriate person at your organization to complete this survey? Yes No 8b. [IF NO] Please provide the name, telephone number, and email address of a person at your organization who is responsible for addressing the needs of youth identified at risk for suicide. Name: _______________________ Telephone Number: _____________ Email: ________________________

[IF NO TO 8a, DO NOT PROCEED]

Professional Development

9a. Within the last year, approximately how many training/ crisis education opportunities have you participated in (either at your organization or at an external organization)?

01	0
02	1-2
03	3-5
04	6-10
05	10+
97	Don’t know
99	Not applicable

9b. Throughout your training and career, approximately how many suicidal youth have you evaluated and/or treated? Please respond based on your overall career, not just your tenure at the agency where you are currently employed.

01	0
02	1-2
03	3-5
04	6-10
05	10+
97	Don’t know
99	Not applicable

Referral Networks

The following organizations have been identified as part of your county level referral network for youth at risk or identified as at risk. Please check all of the organizations that you consider part of your immediate referral network (these should be organizations that you either make referrals to or receive referrals from).

[THIS WILL BE PREFILLED BASED ON THE AGENCIES THAT ARE IDENTIFIED THROUGH SNOWBALL SAMPLING TO BE PART OF THE NETWORK]

• Agency A

• Agency B

• Agency C

[THE FOLLOWING TABLES WILL BE PREFILLED WITH ONLY THE AGENCIES THAT ARE IDENTIFIED ABOVE AS BEING PART OF THE PRIMARY REFERRAL NETWORK]

For those agencies that you identified as part of your immediate referral network, which of the following are the primary aspects of your relationship? (Check all that apply.)	Agency B	Agency D	Agency H	Agency I
Providing referrals
Receiving referrals
Coordination of gatekeeper trainings
Sharing resources (funding, staff, materials, space, etc.)
Sharing information
Creating policies and protocols
Other, please specify:

For those agencies that you identified as part of your immediate referral network, please rate the overall effectiveness of the collaboration.	Agency B	Agency D	Agency H	Agency I
Very ineffective
Ineffective
Neutral
Effective
Very effective
Don’t know
11b. Approximately how many years have you or your organization maintained a relationship with this agency? (If less than 1, please use 99.)
11c. Do you have a formal system in place for sharing information?	01 Yes 02 No 97 Don’t know	01 Yes 02 No 97 Don’t know	01 Yes 02 No 97 Don’t know	01 Yes 02 No 97 Don’t know

Which of the following do you consider barriers to maximizing the potential efforts of your referral network? (Check all that apply.)	Agency B	Agency D	Agency H	Agency I
Lack of protocols and policies
Lack of cooperation between organizations
Lack of resources (funding, staff, materials, space, etc.)
Lack of information about other resources in the community
Lack of knowledge about suicide prevention services
Competition among service providers to meet internal goals and targets
Staff turnover
Other, please describe:

For those agencies you identified as part of your immediate referral network, please provide us with information about the number of referrals and follow-ups over the last 6-month period (these may be based on tracked numbers or estimates).	Agency B	Agency D	Agency H	Agency I
Total number of individuals referred to
Total number of individual referrals received from
Do you follow-up with youth after they have been referred to another agency?	01 Yes 02 No 03 Sometimes 97 Don’t know 99 Not applicable	01 Yes 02 No 03 Sometimes 97 Don’t know 99 Not applicable	01 Yes 02 No 03 Sometimes 97 Don’t know 99 Not applicable	01 Yes 02 No 03 Sometimes 97 Don’t know 99 Not applicable
If yes, approximately what percent of referrals made have been successfully followed-up?
Are these numbers based on tracked numbers or estimates?	Tracked Estimate	Tracked Estimate	Tracked Estimate	Tracked Estimate

14. Are assessments of risk conducted onsite?

1. Yes

2. No

97. Don’t know

14. [IF YES TO 14] Are you aware of formal policies, protocols or guidelines (written or communicated otherwise) at your agency regarding:

Assessment of youth risk	Yes No 97 Don’t know
Addressing the needs of youth who attempt suicide and their families	01 Yes 02 No Don’t know
Following up with (or tracking) youth who are identified as seriously at risk or who have attempted suicide	01 Yes 02 No 97 Don’t know
i. [IF YES] How long do you typically try to continue following-up with youths identified as at risk or as having made a suicide attempt?	01 Next day 02 1 week or less 03 03 Up to 1 month 04 Up to 3 months 05 Up to 9 months 06 1 year or longer 07 No typical length 97 Don’t know 99 Not applicable
ii. [IF YES] What strategies do you use to follow-up with youth identified as “at-risk” or as having made a suicide attempt?	01 Phone calls 02 Text messages 03 Letter 04 Email 05 Home visit 97 Don’t know 99 Not applicable
A designated person who makes decisions in a crisis situation	01 Yes 02 No Don’t know
Provisions of how referrals and follow-ups are documented	01 Yes 02 No 97 Don’t know

14. When reflecting on your current protocol for the following, do you think efforts are not enough, just right or too much:

Risk assessment	01 Not enough 02 Just right 03 Too much 97 Don’t know
Follow-up protocol	01 Not enough 02 Just right 03 Too much 97 Don’t know
Supporting families/youth	01 Not enough 02 Just right 03 Too much 97 Don’t know

14. What is your approach or set of procedures for determining whether or not someone poses high or imminent risk of suicide? (Check all that apply.)

1. Assess suicide thoughts or plans

2. Assess suicidal intent and whether the youth believes s/he can refrain from attempting suicide

3. Assess history of suicide attempts

4. Assessment of family history

5. Assessment of non-suicidal self-injury

6. Assess availability of means for attempting suicide

7. Assess presence of depression and/or hopelessness

8. Assess presence of substance abuse

9. Ask youth to articulate or list reasons for living

10. Ascertain if the youth can agree to a safety contract

11. Try to develop safety plan with youth

12. Meet with youth’s parents or guardians to address concerns and safety issues

13. Immediately refer the youth to speak to a clinician at a referral agency

95 Other (please specify)

97. Don’t know

99 Not applicable

14. For youths identified as high risk, what are your typical procedures for managing these youths? Do you typically engage in any of the following practices? (Check all that apply.)

1. Call or meet with parents or guardians to discuss monitoring

2. Call or meet with parents or guardians to provide education about the need for follow-up treatment

3. Assess safety in the home and discuss safety in the home with parents/guardians (e.g., removing means of suicide such as firearms)

4. Discuss alternative ways of coping with distress, or alternatives to suicide with the youth

5. Discuss reasons for living with the youth

6. Ask youth to agree to a signed no-suicide contract or promise

7. Work with youth to identify individuals the youth can contact if feeling suicidal

8. Refer youth to the emergency department or crisis service

9. Refer youth to a community provider if the youth / family is/are not already in treatment

10. Provide an after-hours emergency contact number to youth

11. Provide an after-hours emergency contact number to parents / guardians

12. If a new referral is given, follow-up with the suicidal youth and family to see if they followed through with treatment recommendation or need assistance with this

13. Follow up with the youth at school to assess ongoing status / risk

14. Provide youth with national suicide hotline or other crisis hotline phone information

15. Follow up to see if they kept appointment

95 Other, please specify:

________________________________________________________________________________________________________________________________________________

97. Don’t know

99 Not applicable

14. What happens when your organization identifies someone at elevated risk for suicidal behavior, or someone that has made a suicide attempt through suicide prevention programs? (Check all that apply.)

01	Referral to mental health professional within the school system (e.g., school social worker or guidance counselor) that has responsibility for the school or agency
02	Referral to emergency room (for evaluation of all youths identified)
03	Referral to emergency room for select cases
04	Referral to mental health provider in the community
05 06	Contact parents/guardians to let them know of the young person’s status (and possibly suggest evaluation and/or treatment) Conduct an in-house clinical assessment
95	Other, please describe:

________________________________________________________________________________________________________________________________________________

14. Once a youth is identified as potentially at risk or as having made a suicide attempt, how long is it usually before someone (either within your organization or within your referral network) can meet with him/her to do a clinical assessment? (Please choose the option that best describes what usually happens.)

01	Immediately
02	Less than 2 hours
03	Less than 4 hours
04	Within the school day
05	Within 2 school days
06	Within a week
07	Longer than a week

14. What are the factors that affect the length of time between identification and clinical assessments? (Check all that apply.)

1. Recent suicide attempt

2. Level of risk

3. Demographic characteristics

04 Clinician availability

05 Insurance or other funding consideration

95 Other, please describe:

____________________________________________________________________________________________________________________________________________

97 Don’t know

99 Not applicable

14. Have you had any direct contact with [GRANTEE NAME]?

1. Yes

2. No

97. Don’t Know

22a. [IF YES] Have you received any gatekeeper trainings through [Grantee name]?

1. Yes

2. No

97. Don’t know

22b. [IF YES TO 22] Select all of the activities that are primary to your relationship with [GRANTEE NAME]?

01	Providing referrals to the organization
02	Receiving referrals from the organization
03	Coordination of Gatekeeper trainings
04	Sharing resources
05	Sharing information
06	Creating policies and protocols
95	Other, please specify
99	Not applicable

14. Identify any barriers or challenges faced by your referral network.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Identify any strategies you have utilized to strengthen the network.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Referral Network Survey Page 15

09.23.13