G. Coalition Surve G. Coalition Survey Instrument and Web Consent

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

Coalition Survey and Consent

Description of Participation

This survey asks about your organization’s involvement in your suicide prevention coalition. This survey is being conducted to better understand how coalition building activities are used to support suicide prevention related activities. It is being administered to all organizations that participate in the coalition.

Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary. You can choose to exit the survey or not answer a question at any time. If you stop the survey, at your request, we will destroy your survey. There are no penalties or consequences to you or your organization for not participating.

The survey will take approximately 40 minutes to complete.

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 support suicide prevention activities. The findings will assist in informing the Substance Abuse and Mental Health Services Administration (SAMHSA) about suicide prevention activities and coalition 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

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

   01	Mental health/behavioral health agency		11 12	Tribal social service agency Tribal government
   02	Child welfare services (i.e., social services) agency		13	College or university
   03 04 05 06 07 08 09 10	K-12 school Juvenile justice agency Police/Law enforcement agency State health department agency Local health department agency Primary care providers Crisis center Tribal health agency		14 15 16 17 18 19 95 97 99	Non-profit community service organization Individual therapist Religious or spiritual organization Political representative (state or local government entity) Community member/private individual Youth volunteer Other Don’t know Not applicable

2. Which of the following most closely aligns with your involvement in the coalition?

01 I am representing an entity/organization

02 I am representing myself as an individual

95 Other, please describe: ______________________________________________________

3. [IF QUESTION 2 IS 01] About how many staff members (full-time or part-time) are employed by your organization?

__ __ Number of Staff Members

97 Don’t know

99 Not applicable

4. How long have you been involved with the coalition efforts?

01 Less than 1 month

02 1 to 6 months

03 7 to 12 months

04 1 to 2 years

05 3 to 5 years

06 More than 5 years

97 Don’t know

99 Not applicable

Coalition

The following entities have been identified as part of your coalition. [THIS WILL BE PREFILLED BASED ON THE AGENCIES THAT ARE IDENTIFIED by the grantee] Please refer to this list when answering the following questions

• Agency A

• Agency B

• Agency C

Mission

5. Is suicide prevention and awareness the primary mission of the coalition?

01 Yes

02 No

97 Don’t know

6. Has the mission of the coalition changed as a result of the GLS grant?

01	Yes
02	No
97	Don’t know

7. [GRANTEE] has identified the following activities as central to the mission of the coalition. Please rate the following activities in terms of what you consider a priority for the coalition. [This will be prefilled based on the grantees response.]

   01	Establishing policies and protocols aimed at building referral networks
   02	Securing funding for future suicide prevention related activities
   03	Developing a sustainability plan for suicide prevention services
   04	Advocating for legislative changes aimed at improving services
   05	Creating protocols and policies for risk assessments and screenings
   06	Meeting/conference/workshop/Webinar planning, coordination and facilitation
   07	Product development (assessments, screenings, Web site, etc.)
   08	Curriculum development
   09	Coordination of an internship program
   10	Outreach activities
   95	Other services, please specify:
   97	Don’t know

8. Which of the activities above do you have direct involvement with as a coalition member?

01	Establishing policies and protocols aimed at building referral networks
02	Securing funding for future suicide prevention related activities
03	Developing a sustainability plan for suicide prevention services
04	Advocating for legislative changes aimed at improving services
05	Creating protocol and policies for risk assessments and screenings
06	Meeting/conference/workshop/Webinar planning, coordination and facilitation
07	Product development (assessments, screenings, Web site, etc.)
08	Curriculum development
09	Coordination of an internship program
10	Outreach activities
95	Other services, please specify:
97	Don’t know

9. Approximately how many hours a month do you, or someone from your agency, dedicate to coalition required activities such as regularly scheduled meetings? __________

10. Approximately how many hours a month do you, or someone from your agency, dedicate to coalition related activities beyond regular meeting attendance _____________  

11. Does the coalition have formal protocols such as a mission statement, participant guidelines, and/or a budget?

01 Yes

02 No

97 Don’t know

12. How are these protocols formalized with members of the coalition? (Check all that apply.)

1. Memorandums of Understanding

2. Contracts

3. Verbal agreement

4. Other, please specify: ___________________________

Effectiveness of the Coalition

13. Please rate the overall effectiveness of the coalition in accomplishing the activities identified as central to the mission of suicide prevention

	01	Not effective
	02	Somewhat effective
	03	Neutral
	04	Moderately effective
	05	Very effective
	97	Don’t know
Please rate the following statements:			Strongly Disagree	Disagree	Neutral	Agree	Strongly Disagree
The coalition is moving in the right direction to achieve its stated goals.
The GLS grantee has contributed to the coalition in a meaningful way.
Subgroups or smaller committees within the coalition are considered an effective strategy to accomplish specific tasks.
There is an expectation that all members of the coalition talk together and are willing to listen to another perspective.
I consider the relationships in the coalition to be bi-directional.

15. [IF QUESTION 2 IS RESPONSE 01] Please rate how you feel the coalition contributes to the mission of your agency in joining the coalition.

    01	No contribution
    02	Contributes very little
    03	Neutral
    04	Contributes somewhat
    05	Contributes a lot
    97	Don’t know

16. [IF QUESTION 2 IS RESPONSE OPTION 02 OR 03] Please rate how you feel the coalition contributes to your personal goals for joining the coalition.

01	No contribution
02	Contributes very little
03	Neutral
04	Contributes somewhat
05	Contributes a lot
97	Don’t know

17. [IF QUESTION 2 IS RESPONSE OPTION 1], Please rate how you feel your agency contributes to the mission of the coalition.

01	No contribution
02	Contributes very little
03	Neutral
04	Contributes somewhat
05	Contributes a lot
97	Don’t know

18. What are the challenges or barriers associated with the overall functioning of the coalition?

01	Lack of time of participating members
02	Lack of financial resources
03	Lack of coordination and oversight
04 05	Lack of clarity about the coalition’s mission Other, please specify
97	Don’t know

19. How was your participation in the coalition initiated?

01 A small leadership team contacted me directly about joining the coalition

02 Someone at my agency (besides me) was contacted directly about the coalition

03 I, or someone at my agency, reached out to other organizations to form a coalition

04 I, or someone at my agency, responded to a posting/call for coalition members

95 Other, please specify:

97. Don’t know

20. Aside from coalition-specific collaboration, have you established working relationships for other purposes with individuals or agencies/members of the coalition? Please don’t include the work you do for the coalition in your answer.

01 Yes

02 No

97 Don’t know

Sustainability

21. Do you consider sustainability of suicide prevention related activities to be part of the coalition’s mission?

1. Yes

2. No

97. Don’t know

22. If yes, what suicide prevention activities are the focus of your sustainability planning? (Check all that apply.)

1. Maintaining the coalition

2. Establishing policies and protocols

3. Securing funding for future suicide prevention activities

4. Advocating for legislative change

5. Meetings/conferences/workshops

6. Product development

7. Curriculum development

8. Coordination of an internship program

9. Outreach activities

95. Other, please specify:

23. Do you consider the coalition activities to be sustainable without GLS funding?

1. Yes

2. No

3. Some

97. Don’t know

24. What aspects of your coalition support your ability to sustain/maintain these suicide prevention activities?  (Check all that apply.) 

1. Use of a train the trainer model

2. Identification of additional funding

3. Collaboration with stakeholders

4. Continuation of regular communication

5. Revenue generation through product development

6. Use of volunteers/interns

7. An individual/group of individuals to spearhead the cause

8. Community support

95. Other, please specify:

25. What would be one recommendation you would have for agencies/individuals interested in developing a coalition aimed at suicide prevention?

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Coalition Survey Page 11

09.23.2013